Standards For Wound Prevention and Management 2016

STANDARDS
FOR
WOUND PREVENTION
AND MANAGEMENT
Third Edition
Copyright © Wounds Australia, 2016
Standards for Wound Prevention and Management
3rd edition
ISBN 978-0-9807396-9-5
Previous ISBN 978-0-9807842-0-6
Published by Cambridge Media on behalf of Wounds Australia
Healing Wounds Together
First edition published: 2002

Second edition published: 2010
All rights reserved
Suggested citation:
Wounds Australia. Standards for Wound Prevention and Management. 3rd edition.
Cambridge Media: Osborne Park, WA; 2016
Disclaimer:
The Standards were developed by Wounds Australia. They represent the best available
evidence at the time of publication related to wound prevention and management.
The Standards reflect appropriate clinical practice, to be implemented by qualified
health care professionals subject to their clinical judgment of each individual case
and in consideration of the individual’s personal preferences and local policies. The
Standards should be implemented in a culturally aware and respectful manner in
accordance with the principles of protection, participation and partnership.
Printed copies of Standards for Wound Prevention and Management (3rd edition) can
be ordered from Wounds Australia: http://www.woundsaustralia.org.au/
Introduction
Preface
Wounds Australia is an interdisciplinary professional association for individuals with

an interest in wound prevention and management. The objectives of Wounds
Australia are to raise awareness of the science and art of wound prevention and
management, and to promote evidence based wound management practices.
The Standards for Wound Prevention and Management presented in this revised
third edition provide a framework for promoting best practice in wound prevention
and management as they reflect current evidence. The Standards are a valuable
tool for guiding clinical practice and the development of policies, procedures and
education programs. The aim of the Standards is to facilitate quality care outcomes
for individuals with wounds or at risk of wounding
It is the ongoing vision of Wounds Australia that these Standards will continue to be
adopted by health care professionals, health care workers, educators and service
providers across Australia, and that the challenge associated with validating and
embedding the Standards across all practice and educational settings be taken up
enthusiastically.
Acknowledgement
The third edition of the Standards for Wound Prevention and Management has been
revised by the Standards Subcommittee in consultation with Wounds Australia. An
expression of appreciation is extended to the Standards Subcommittee:
Professor Keryln Carville, PhD, STN(Cred), RN, MRCNA, FAWMA

Juliet Scott, MN(NP), B App Sc (Primary Health), Grad Dip DN, Dip of Derm, RN
Associate Professor Emily Haesler, PhD, BN, P Grad Dip Adv Nurs(Gerontics)
The third edition builds on the work completed for the first and second editions of
the Standards. Appreciation and recognition is extended to previous subcommittee
members for their contributions to the development of the 2002 and 2010 editions,
which informed the third edition.
The contributions of Australian individuals, peak bodies and organisations who

responded to the invitation to review the draft third edition of the Standards is
acknowledged with gratitude.
Standards for Wound Prevention and Management 1

Introduction
CONTENTS
Preface.............................................................................................................. 1
Acknowledgements ....................................................................................... 1
Introduction...................................................................................................... 3
STANDARD 1: Scope of Practice..................................................................... 4
STANDARD 2: Collaborative Practice............................................................. 8
STANDARD 3: Clinical Decision Making: Assessment................................ 14
STANDARD 4: Clinical Decision Making: Planning and Practice.............. 25
STANDARD 5: Documentation....................................................................... 39
STANDARD 6: Education................................................................................ 44
STANDARD 7: Corporate Governance......................................................... 48
Glossary of Terms........................................................................................... 52
2 Standards for Wound Prevention and Management

Introduction
INTRODUCTION
Standards of care play a role in identifying expected levels of care that should be
delivered to individual’s receiving wound prevention and management. Standards
contribute to ensuring that care delivery is of a consistent high level and that
unwarranted variation is reduced. Standards play a role in improving safety of the
individual and promoting positive outcomes of care (for example, and reducing
avoidable wounds and promoting wound healing). The Standards presented in this
document are intended for use by individual health care professionals and health
care workers for monitoring their own care delivery standards and identifying areas
for professional development. They may also be used by health care services to
develop policies and procedures, design education programs, audit clinical care
and undertake staff appraisal. The Standards may be used by individuals receiving
care and their informal carers to identify the standard of care that they can expect
when receiving wound prevention and management. The Standards should be
used in conjunction with other clinical care standards, accreditation standards and
professional standards.
There are seven core Standards in the third edition of Standards for Wound Prevention
and Management. The Standards address key components of wound prevention
and management, including the scope under which health care professionals and
health care workers practice, working in collaboration, clinical decision making
(two standards that focus on assessment, planning and practice), documentation,
education and corporate governance. Each Standard outlines an expected level
of care and includes a rationale and evidence criteria that demonstrate that the
standard has been reached. A background and context is included as extended
information.
The Standards presented in this third edition build on those in previous editions.
A targeted literature search was undertaken in medical databases, legislature
databases and Google Scholar to identify relevant references published since the
previous edition in 2008. Relevant key documents were reviewed from other organisations
(e.g. Australia Health Practitioner Regulation Agency and Australian Commission on
Safety and Quality in Health Care) and relevant evidence-based clinical guidelines were
reviewed. The references included in the previous editions were also reviewed for their
ongoing relevance to current practice.
The third edition of Standards for Wound Prevention and Management underwent an
extensive stakeholder review that was advertised on the Wounds Australia website.
Over 30 key organisations (e.g. professional bodies, educational organisation and
peak bodies) were also invited to review the Standards. All feedback was reviewed
by the development team and incorporated into the Standards for Wound
Prevention and Management as appropriate.

Standard 1
STANDARD 1
SCOPE OF PRACTICE
Safety and wound healing potential of the individual is enhanced
by practice that respects and complies with legislation,
regulations, scope of practice, service provider policies, current
evidence and ethics.
Rationale
Practising within the legal boundaries of scope of practice and complying with
legislation and regulations is a requirement of professional practice. Implementing
wound prevention and management that reflects current best practice is associated
with positive outcomes.
Criteria
Scope of practice includes:
1.1. Performance in accordance with legislation, regulations, scope of practice

and service provider policies.1-9
Evidence Criteria
1.1.1. Function in accordance with the scope of practice as determined by

regulatory authorities.
1.1.2. Accountability for practice.
1.1.3. Awareness of limitations of scope of practice for regulated and non-

regulated practice.
1.1.4. Knowledge of, and compliance with, policies and procedures of

relevant service providers.
1.2. Implementation of evidence-based wound prevention and management.10-13
Evidence Criteria
1.2.1. Ability to access current evidence from reputable sources to maintain a

professional knowledge base.2, 3, 7, 14
1.2.2. Care decisions reflect evidence-based practice.5, 9, 12

Standard 1
1.2.3. Safe use of products, pharmaceuticals, therapies and devices in

accordance with the manufacturers’ instructions and the Therapeutic
Goods Administration guidelines.2, 5-7, 9, 12, 15
1.3. Provision of care within an ethical practice framework.2, 3, 5, 7, 15-17
Evidence Criteria
1.3.1. Recognises the responsibility to prevent harm to the individual and their
informal carers.
1.3.2. Recognises the rights and responsibilities of the individual, interprofessional

team, health care workers and informal carers.
1.3.3. Delivers evidence-based wound prevention and management that is

sensitive to beliefs, values, culture and dignity.
1.3.4. Addresses moral and ethical dilemmas in delivery of wound prevention

and management.
Background and Context

Scope of practice
Scope of practice refers to the area of practice in which a health care professional
or health care worker is educated, competent and legally permitted to perform
services. The scope of practice for these individuals is determined by their educational
background, status with an Australian health care registration body and the law
and regulations pertaining to their clinical field.2
Standards for practice for health care professionals provide minimum expected
standards for delivering health care to individuals across a range of clinical settings
and include professional attributes that underpin competent performance in the
health care domain.2 The values, skills, knowledge and abilities expected of a health
care professional are outlined in relevant national core competency standards.1, 2,
4, 5, 7, 8
Beyond the minimum education requirements, legal requirements, and competency

standards, scope of practice may also be influenced by:1, 2, 18
• the level of competence and confidence a health care professional or health
care worker has in performing specific clinical care, and
• policies and procedures put in place by the service provider.
Scope and standards of practice promote the respect, dignity, safety and wellbeing
of the individual, interprofessional team, health care workers and informal carers.1
It is recognised that the scope of practice varies according to the individual’s role.
For example, health care professionals work within a professional framework that
requires ongoing development, self-reflection and professional judgement and
decision making.4, 7, 16, 18 While accountable for their practice, health care workers
are not expected to have the same knowledge level, experience or decision making
responsibilities as health care professionals.18

Standard 1
It is expected that all health care professionals and health care workers have a strong
understanding of the scope and standards defining their own practice and that of
their colleagues, and are able to identify and negotiate breaches of practice scope
in order to ensure that the care provided to individuals meets expected standards.1,
5, 7
Being aware of the limitations to the practice of others is particularly important for
those who have delegation roles. When delegation is undertaken, both parties are
responsible for ensuring appropriate assignment of care activities.3-5
Evidence-based practice
Health care professionals have a responsibility to engage in evidence-based practice

through promotion of care strategies that have been shown to be efficacious.
An important component of clinical practice is engagement in evidence-based
practice. Evidence-based practice requires continuous professional development
through the ongoing questioning of one’s clinical practice, seeking out evidence
from a range of reputable sources to inform and evaluate practice and, where
possible, engaging in research activities to add to the body of evidence in wound
prevention and management.9, 10 Evidence based wound practice involves
conscientious and judicious evaluation of the best available evidence to inform the
way in which wound prevention and management is delivered.9, 12-14
Consideration should be given to meaningful outcomes for specific individuals

with a wound or at risk of wounding, and selection of interventions that promote
wound prevention and healing, maintenance wound management, quality of
life, cost effectiveness and minimal risk.7, 10 This requires a structured approach to
wound prevention, assessment and management.11 Clinical practice guidelines
developed using evidence-based approaches provide one source by which the
interprofessional team and health care workers can review evidence underpinning
care options and recommendations for prevention and management of wounds.11,19
However, implementation of evidence-based principles of wound prevention and
management requires an interprofessional approach, with consideration to the
knowledge and skills of the entire team, the individual’s preferences, resources
available, local policies and procedures and the context of care.14, 20-22
Evidence-based practice incorporates the safe and effective delivery of care.9, 12

Members of the interprofessional team who take responsibility for prescription and
delivery of pharmacological and non-pharmacological therapeutic interventions
are accountable for ensuring therapies are selected in the best interest of individuals,
and are delivered safely and in accordance with manufacturer directions,
Therapeutic Goods Administration licensing and are evaluated for effectiveness.2, 3
Ethical practice
Ethical practice requires consideration of what is morally right and wrong, and the
potential outcomes of actions.17 The fundamental principle guiding health care is
the recognition of the individual’s rights and promotion of dignity. Guiding principles
in delivering ethical care include valuing the individual, valuing respect and
kindness and valuing diversity. Promoting access to quality wound prevention and
management, informed decision-making on behalf of individuals, safety, privacy
and sustainable wellbeing are core strategies by which the interprofessional team
and health care workers can deliver ethical care.16

Standard 1
References
1. Nursing and Midwifery Board of Australia. Code of Professional Conduct for Nurses in
Australia. 2008, Melbourne: Nursing and Midwifery Board of Australia.
2. Nursing and Midwifery Board of Australia. Nurse Practitioner Standards for Practice. 2014,
Melbourne: Nursing and Midwifery Board of Australia.
3. Nursing and Midwifery Board of Australia. Registered Nurse Standards for Practice. 2016,
Nursing and Midwifery Board of Australia: Melbourne.
4. Nursing and Midwifery Board of Australia. Standards for Practice: Enrolled Nurses. 2016,
5. Physiotherapy Board of Australia. For Registered Health Practitioners: Code of Conduct.
2014, Physiotherapy Board of Australia, http://www.physiotherapyboard.gov.au/.
6. Pharmacy Board of Australia. For Pharmacists: Code of Conduct. 2014, Pharmacy Board
of Australia: http://www.pharmacyboard.gov.au/.
7. Podiatry Board of Australia. For Registered Health Practitioners: Code of Conduct. 2014
Podiatry Board of Australia: http://www.podiatryboard.gov.au.
8. Medical Board of Australia. Good Medical Practice: A Code of Conduct for Doctors in
Australia. 2014, Medical Board of Australia: http://www.medicalboard.gov.au/.
9. Australian Commission on Safety and Quality in Health Care. National Safety and Quality
Health Service Standards. 2012, ACSQHC: Sydney.
10. Harding K. Evidence and wound care: what is it. Journal of Wound Care, 2000. 9(4): 188.
11. Beeckman D, Duprez V. The journey to evidence-based practice. British Journal of
Nursing, 2011: S3.
12. van Rijswijk L, Gray M. Evidence, research, and clinical practice: a patient-centered
framework for progress in wound care. Journal of Wound, Ostomy & Continence Nursing,
2012. 39(1): 35-44.
13. Al-Benna S. A discourse on the contributions of evidence-based medicine to wound
care. Ostomy Wound Management, 2010. 56(6): 48-54
14. Woodward M. Using the journal to improve patient care. Wound Practice & Research,
2012. 20(4): 172.
15. Australian Medical Association. AMA Code of Ethics. 2006, Australian Medical Association,
https://ama.com.au/.
16. Nursing and Midwifery Board of Australia. Code of Ethics for Nurses in Australia. 2008,
17. Welsh L. Ethical issues and accountability in pressure ulcer prevention. Nursing Standard,
2014. 29(8): 56-63.
18. Nursing and Midwifery Board of Australia. A National Framework for the Development of
Decision-making Tools for Nursing and Midwifery Practice. 2007, Melbourne: Nursing and
Midwifery Board of Australia.
19. Al-Benna S. Construction and use of wound care guidelines: an overview. Ostomy Wound
Management, 2012. 58(8): 37-47.
20. National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel
(EPUAP), Pan Pacific Pressure Injury Alliance (PPPIA). Prevention and Treatment of Pressure
Ulcers: Clinical Practice Guideline. 2014: Emily Haesler (Ed.) Cambridge Media: Osborne
Park, WA.
21. Australian Wound Management Association (AWMA), New Zealand Wound Care Society
(NZWCS). Australia and New Zealand Clinical Practice Guideline for Prevention and
Management of Venous Leg Ulcers. 2012 Cambridge Media: Osborne Park, WA.
22. Australian Wound Management Association (AWMA). Pan Pacific Clinical Practice
Guideline for the Prevention and Management of Pressure Injury. 2012, Cambridge
Media: Osborne Park, WA.

Standard 2
STANDARD 2
COLLABORATIVE PRACTICE
Wound prevention and management is delivered using a
collaborative approach between the individual, interprofessional
team, health care workers and informal carers.
Rationale
Collaborative practice in wound management is associated with wound prevention,
improved wound healing time and other positive outcomes (e.g. improved quality
of life) for the individual, interprofessional team, health care workers and the health
care system.1-8
Criteria
Collaborative wound prevention and management includes:
2.1. Empowerment of the individual and their informal carers to participate in

health care decisions and wound management.1, 9-14
Evidence Criteria
2.1.1. Assessment of the health literacy of the individual and their informal
carers, including their capacity to engage in informed decision making.
2.1.2. Provision of information to the individual and their informal carer on:
• Rights and responsibilities in wound prevention and management.
• The purpose of and options for a comprehensive assessment.
• The outcomes from all assessments, including the ongoing progress of

wounds.
2.1.3. Opportunities and information exchange that encourage and facilitate

participation of the individual and their informal carers in wound
prevention and management.
2.1.4. Individuals with non-concordant behaviours receive education, support

and respect that will guide future care directives and access to service
delivery.

Standard 2
2.2. Communication that facilitates collaboration and coordination of care.1, 3, 9, 14-18
Evidence Criteria
2.2.1. Communication is undertaken in a manner that is consistent with the

individual’s values, preferences, language and health literacy.
2.2.2. Regular, documented communication between the individual,
interprofessional team, health care workers and informal carers.
2.2.3. Timely communication when there are changes that impact on the
individual, their wound and/or their wound healing environment.
2.2.4. Discussion with the individual and their informal carer regarding
preferences, ability and willingness to participate in care decisions and
interventions.
2.3. Recognition of the skills, knowledge, and contributions of the individual,

interprofessional team, health care workers and informal carers with respect
to prevention and management of wounds.1, 3, 16, 18-22
Evidence Criteria
2.3.1. Awareness of the skills, knowledge and scope of practice of individual

team members.
2.3.2. Referral to other members of the interprofessional team when care
decisions or management are outside the skills, knowledge and scope
of practice.
2.3.3. Support the ongoing professional development of other team members.
2.4. Recognition of the cultural diversity and setting of the individual, interprofessional
team, health care workers and informal carers.14
Evidence Criteria
2.4.1.
Assessment of the individual and their informal carers’ cultural
background and linguistic preferences.
2.4.2. Use of interpreter when required.
2.4.3. Cultural practice and preferences are acknowledged and respected.

Collaborative care
A collaborative team of individuals from a range of health care professions working
with health care workers, the individual and their informal carer is considered to
be a gold standard for wound prevention and management and is central to

Standard 2
collaborative care.1, 15 Health care professionals and health care workers rarely work
in complete isolation from peers within their service or others delivering health care
to the same individuals with, or at risk of, wounds; however wound management is
often delivered in an uncoordinated manner by a range of services.23 Over 80% of
Australian individuals with a leg ulcer will be managed in the primary care setting with
involvement of a general practitioner and/or a general practice nurse.23 Community
nurses provide home-based or service-based care to individuals with wounds, usually
following referral from a medical practitioner or hospital service, and sometimes in
conjunction with a medical specialist.23 Allied health care professionals also work
with medical specialists or general practitioners to deliver wound prevention and
management in community or primary care settings.23 Adopting a collaborative
approach to health care delivery is recognised as a core component of professional
practice across health care disciplines and settings9, 19, 23 and is encouraged as a
cost-effective and safe model23 that promotes the needs of both the individual and
care providers.
Wound management is a multifactorial clinical issue that frequently encompasses

the expertise of many health disciplines to prevent and manage wounds and to
consider co-morbidities.20 Evidence-based wound management guidelines highlight
that collaboration between the individual, interprofessional team, health care
workers and informal carers is as an essential component of good quality care.24-27
Collaborative wound management promotes integration into wound assessment
and management of complementary perspectives, philosophies and strategies that
are derived from the expertise of interprofessional team members and health care
workers from varying professional and clinical backgrounds.22 This includes timely and
appropriate address of intrinsic and extrinsic factors that influence an individual’s
wound healing, early consideration of risk indicators and wound deterioration,
prompt referral, and comprehensive documentation.2
A collaborative approach to wound prevention and management is associated

with decreased incidence of preventable wounds, improved wound healing times,
reduced amputation rates, improved quality of life and more cost-effective care.1-8,23
One comprehensive systematic review1 explored evidence on collaborative wound
management in inpatient and community health care settings in urban, rural and
remote regions. Data from 76 studies that included care models for individuals with
diabetic foot ulcers (DFUs), pressure injuries (PIs) and venous leg ulcers (VLUs) were
reviewed. Studies reported a range of collaborative team models that were based
on various conceptual models of wound prevention and management, with the
expertise of team members and size and structure of teams varying significantly
based on aetiology of the wound. Reported outcomes included decrease in
amputation rates in individuals with DFU; reduction in PI incidence; faster average
healing rates for DFUs, chronic wounds and recalcitrant VLUs; increased adherence
to self-care management plans; improved satisfaction for individual’s receiving care;
and enhanced health-related quality of life. Cost savings reported in the included
literature included reduced clinician time and consolidation of services.1
Empowering individuals
The right of individuals to independence, choice, and control over their health
care are enshrined in quality standards for acute care, sub-acute care, aged care
and community-based care in Australia.10, 12-14 A patient-centred approach to care
requires the interprofessional team and health care workers to maintain respect for
individuals and support and promote engagement in their own care. In order to
make choices about their wound management, to contribute to goal and care

Standard 2
planning and to actively engage in activities that promote prevention or healing of

wounds. individuals require an appropriate level of health literacy, education and
support. Promotion of quality care includes key strategies at a system, service, team
and individual level.11, 14 These strategies include (but are not limited to):10-14
• developing service policies that promote partnership with the individual and
informal carers;
• assessment of the individual’s ability to engage in care decisions and undertake

self-care;
• provision of education and support to allow individuals and informal carers to

develop the necessary skills to engage in care decisions and undertake self-
care; and
• recognition of the diverse backgrounds of individuals that require consideration

in delivery of wound prevention and management.
Such a patient-centred approach is associated with improved preventive care,

increasing functional status, concordance in goals and wound management
strategies, reduced complication and infection rates and fewer adverse outcomes.11
However, the interprofessional team must uphold the right of individuals who choose
alternative goals of care or wound management strategies despite the provision of
education, support and guidance.
Working in a team
Successful collaboration requires individuals to work together as a group within and

across health care settings to communicate effectively. Effective communication
requires team members to make appropriate and timely referrals, share information;
negotiate, plan and act; give and receive feedback; respect one another; and
resolve conflict in order to achieve identified mutual goals and optimum outcomes
for the individual at risk of, or with, wound.16, 17, 28 Personal characteristics including
clinical expertise, communication and leadership skills, and self-reflection are core
facilitators to collaborative team work.5, 18 Having a thorough appreciation and
acknowledgement of the scope of practice and skills set of other wound management
team members is a fundamental principle of successful collaboration.21,22
Supporting other members of the team in their professional development (e.g.
through sharing of educational opportunities, discussing research or supporting
opportunity to engage in professional development activities) is a part of successful
collaboration.
References
1. Moore Z, Butcher G, Corbett L, McGuiness W, Synder R, van Acker K. AAWC/AWMA/
EWMA Position Paper: Managing wounds as a team. Journal of Wound Care, 2014. 23(5
Suppl): S1-38.
2. Armstrong DG, Bharara M, White M, Lepow B, Bhatnagar S, Fisher T, Kimbriel HR, Walters J,
Goshima KR, Hughes J, Mills JL. The impact and outcomes of establishing an integrated
interdisciplinary surgical team to care for the diabetic foot. Diabetes/Metabolism
Research and Reviews, 2012. 28(6): 514-8.

Standard 2
3. Gottrup F. A specialized wound-healing center concept: importance of a multidisciplinary

department structure and surgical treatment facilities in the treatment of chronic wounds.
The American J of Surg, 2004. 187(Supp 1): 38S-43S.
4. Valdes A, Angderson C, Giner J. A multidisciplinary, therapy-based, team approach

for efficient and effective wound healing: A retrospective study. Ostomy Wound
Management, 1999. 45(6): 30-6.
5. Acker KV. Employing interdisciplinary team working to improve patient outcomes in

diabetic foot ulceration - our experience. EWMA Journal, 2012. 12(2): 31-5
6. Stern A, Mitsakakis N, Paulden M, Alibhai S, Wong J, Tomlinson G, Brooker AS, Krahn M,

Zwarenstein M. Pressure ulcer multidisciplinary teams via telemedicine: a pragmatic
cluster randomized stepped wedge trial in long term care. BMC Health Services Research,
2014. 14: 83.
7. Chiu CC, Huang CL, Weng SF, Sun LM, Chang YL, Tsai FC. A multidisciplinary diabetic foot
ulcer treatment programme significantly improved the outcome in patients with infected
diabetic foot ulcers. Journal of Plastic, Reconstructive & Aesthetic Surgery, 2011. 64: 867-
72.
8. Rerkasem K, Kosachunhanun N, Tongprasert S. A multidisciplinary diabetic foot protocol

at Chiang Mai University Hospital: cost and quality of life. International Journal of Lower
Extremity Wounds, 2009. 8(3): 153-6.
9. Nursing and Midwifery Board of Australia. A National Framework for the Development of
Decision-making Tools for Nursing and Midwifery Practice. 2007, Melbourne: Nursing and
Midwifery Board of Australia.
11. Australian Commission on Safety and Quality in Health care. Patient-centred care:
Improving quality and safety through partnerships with patients and consumers. 2011,
ACSQHC: Sydney.
12. Australian Government Department of Health. Charter of Care Recipients’ Rights and
Responsibilities - Home Care, Aged Care Act 1997, Schedule 2 User Rights Principles 2014
2015, DoH: Canberra.
13. Australian Government. Quality of Care Principles 2014, Compilation No. 2, in

F2016C00451, Federal Register of Legislation, Editor. 2016, Australian Government: https://
www.legislation.gov.au/Details/F2016C00451.
14. Australian Commission on Safety and Quality in Health Care. DRAFT. National Safety and
Quality Health Service Standards. Version 2. 2016: Sydney.
15. Plummer ES, Albert SG. Diabetic foot management in the elderly. Clinics in Geriatric
Medicine, 2008. 24: 551-67.
16. Gerardi D, Fontaine D. True collaboration: envisioning new ways of working together.
AACN Advanced Critical Care, 2007. 18(1): 10-4.
17. Dodds S. Shared community-hospital care of leg ulcers using an electronic record and
telemedicine. Lower Extremity Wounds, 2002. 1(4): 260-270.
18. Shiu ATY, Lee DTF, Chau JPC. Exploring the scope of expanding advanced nursing
practice in nurse-led clinics: A multiple-case study. Journal of Advanced Nursing, 2012.
68(8): 1780-92.

Standard 2
19. Hand T. The developing role of the HCA in general practice. Practice Nurse, 2012. 42(19):
14-7.
20. Bogie KM, Ho CH. Multidisciplinary approaches to the pressure ulcer problem. Ostomy
Wound Management, 2007. 52(10): 26-32.
21. Atwal A, Caldwell K. Nurses’ perceptions of multidisciplinary team work in acute health-
care. International Journal of Nursing Practice, 2006. 12(6): 359-60.
22. Choi BC, Pak AW. Multidisciplinarity, interdisciplinarity and transdisciplinarity in health
research, services, education and policy: 1. Definitions, objectives, and evidence of
effectiveness. Clinical and Investigative Medicine, 2006. 29(6): 351-64.
23. Norman RE, Gibb M, Dyer A, Prentice J, Yelland S, Cheng Q, Lazzarini P, Carville K, Innes-
Walker K, Finlayson K, Edwards H, Burn E, Graves N. Improved wound management at
lower cost : a sensible goal for Australia. International Wound Journal, 2016. 13(3): 303-
316.
Park, WA.
25. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJG, Armstrong DG, Deery HG, Embil JM,
Joseph WS, Karchmer AW, Pinzur MS, Se E. 2012 Infectious Diseases Society of America
Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections.
Clinical Infectious Diseases, 2012. 54(12): 132-73.
28. Abrahamyan L, Wong J, Pham B, Trubiani G, Carcone S, Mitsakakis N, Rosen L, Rac VE,
Krahn M. Structure and characteristics of community-based multidisciplinary wound
care teams in Ontario: An environmental scan. Wound Repair & Regeneration, 2015.
23(1): 22-9.

Standard 3
STANDARD 3
CLINICAL DECISION MAKING: ASSESSMENT
A comprehensive, ongoing assessment of the individual, their
wound and the healing environment is performed.
Rationale
Clinical decision making is underpinned by documented, comprehensive initial
and ongoing assessment of intrinsic and extrinsic factors that influence the risk of
wounding and the ability of a wound to heal. Ongoing assessment of the individual,
their wound and the healing environment is required to monitor the efficacy of
wound prevention and management interventions, and strategies used to promote
the individual’s health-related quality of life. Effective care planning is based on
reliable clinical assessment.
Criteria
Comprehensive assessment is demonstrated through:
3.1. A comprehensive and ongoing assessment of the individual.
Evidence Criteria
3.1.1. Comprehensive and ongoing assessment of the individual’s health
and wellbeing related to wound healing and/or risk of wounding is
conducted and documented, which may include:1-6
• Language and need for interpreter service.
• Cultural sensitivities.
• Reason for presentation.
• Cognitive ability.
• Health literacy.
• Wellbeing and socioeconomic status.
• Sensitivities and allergies.
• Age and specific age-related changes.
• Health history and co-morbidities that impact wound healing.
• Previous wound history, treatments and outcomes.

Standard 3
• Previous relevant diagnostics and investigations.

• Medication history, including prescription, over-the-counter
medications (including vitamin supplements), recreational/social drug
use and alternative preparations (e.g. homeopathic medication).
• Nutritional status.
• Pain.
• Vital signs.
• Perceptions, preferences, wound healing goals, and ability to

participate in self-care.
3.2. A comprehensive and ongoing assessment of risk of wounding.
Evidence Criteria
3.2.1. Skin assessments as appropriate to the individual, which may include:
• Risk assessment for pressure injuries, falls, skin tears and incontinence.1, 3
• Lower leg vascular assessment that includes skin colour changes,
palpation of pulses, an ankle brachial pressure index (ABPI) and/or toe
brachial pressure index (TBPI), and transcutaneous oxygen pressure.7
• High risk foot assessment that includes testing loss of protective

sensation (e.g. monofilament) or testing blunt/sharp pressure, touch,
vibratory sensation (e.g. tuning fork or biothesiometer), and reflexes
(e.g. patella hammer).7, 8
3.2.2. Risk assessments are conducted using reliable and valid risk assessment
tools, and according to local policies and procedures.1, 3
3.3. A comprehensive and ongoing assessment of the individual’s wound.
Evidence Criteria
3.3.1. Initial and ongoing comprehensive, documented wound assessments
record, for example: 1-4, 9-15
• Type of wound (e.g. leg ulcer, pressure injury).
• Aetiology and original mechanism of wounding (e.g. venous
insufficiency, pressure).
• Duration of wounding.
• Anatomical location.
• Wound dimensions, for example:
o Length, width and depth measured at the longest/deepest part of
the wound.
o Probing to determine any undermined edges or sinus tracking.

Standard 3
o Wound area measured by wound circumference tracing and

planimetry.
o Wound volume measured using sterile fluid or filler inserted into the
wound.
• Clinical characteristics of wound bed, (e.g. agranulation, granulation,
hypergranulation epithelialisation, slough, necrosis/eschar, exposed
bone or tendon, foreign body, fistula).
• Wound edge characteristics (e.g. level, raised, rolled, undermined,
colour)
• Peri-wound and surrounding skin characteristics (e.g. erythema,
oedema, induration, maceration, desiccation, dermatitis/eczema,
callus, hyperkeratosis, changes in pigmentation, urticaria and
temperature).
• Exudate, for example:
o Type (e.g. serous, haemoserous, sanguineous, seropurulent,
purulent).
o Consistency (e.g. thick or thin).
o Amount.
o Odour.
• Phase of wound healing (e.g. haemostasis, inflammation,
reconstruction, maturation/remodelling).
• Signs and symptoms of inflammation or infection.16
• Digital photography or technologies may be used to document

wound size and appearance in conjunction with above assessments.9
3.3.2. Assessment of wound infection, for example:1-5, 8, 10, 14
• Extent of infection (e.g. local infection, spreading infection, systemic

infection) based on clinical signs and symptoms and/or investigations
(e.g. wound culture).
3.3.3. Classification of the wound using a validated tool for that wound type
where such a tool exists (e.g. pressure injuries, burns, skin tears, venous
leg ulcers and diabetic foot ulcers).1-3, 14, 17-19
3.3.4. Initial and ongoing assessment of wound pain, which considers
both verbal and non-verbal cues and includes documented assessment
of:1-4, 7, 10, 11
• Aetiology and presentation, for example:
o Non-cyclic wound pain (e.g. associated with suture removal or
debridement).
o Cyclic wound pain (e.g. associated with change of wound
dressings).

Standard 3
o Chronic wound pain (e.g. not related to intervention).

• Characteristics of pain, using a valid and reliable pain assessment tool
and including:
o Location, including any radiating or referred pain.
o Character of the wound-related pain (e.g. burning, itching,
stabbing, shooting).
o Intensity of the wound-related pain (e.g. using a numerical rating
scale, visual analogue scale or Wong-Baker FACES tool).
o Duration of wound-related pain.
• Factors that contribute to wound-related pain (e.g. repositioning).
• Factors that relieve wound-related pain (e.g. warmth, quiet,
positioning).
• Impact of pain on quality of life and well-being.
3.3.5. Evaluation of wound healing progress and capacity to heal.4, 7, 15, 20-22
3.4. A comprehensive and ongoing assessment of the individual’s healing

environment that identifies factors that could impact on confidentiality, safe
performance of procedures, infection control or wound healing is performed.
Evidence Criteria
3.4.1. Assessment of the surrounding environment with respect to physical
safety for the individual, informal carers and the interprofessional team.
3.4.2. Assessment of the hygiene of the surrounding environment and any risks
to wound contamination or spread of infection.
3.4.3. Assessment of the individual’s lifestyle and identification of factors that

may impact on wound healing or risk of wounding.10
3.4.4. Assessment of the impact on wound healing of medications/drugs

(prescribed, recreational and over-the-counter) and skin care products.
3.4.5. Assessment of environmental factors that may influence wound healing

(e.g. temperature, humidity).
3.4.6. Assessment of the capacity for hygienic and secure, wound-related

equipment, medications and topical preparations.
3.4.7. Assessment of the privacy offered with the environment (e.g. confidential
storage of the individual’s records and confidential communication).
3.5. Appropriate diagnostic investigations are performed when clinically indicated

to ascertain a definitive diagnosis or identify reasons for delayed wound
healing and the outcomes are documented.

Standard 3
Evidence Criteria
3.5.1. Biochemical analysis is used when indicated, for example:1-3
• Blood glucose and HbA1c.
• Haemoglobin.
• Plasma albumin.
• Lipids.
• Urea and electrolytes.
• Rheumatoid factor.
• Auto antibodies.
• White cell count.
• Erythrocyte sedimentation rate.
• C-reactive protein.
• Liver function tests.
3.5.2. Microbiology is used when indicated, for example:1-3, 8, 23-25
• Wound swab for semi-quantitative and quantitative organisms.
• Needle aspiration for quantitative organisms.
• Wound/bone biopsy for quantitative organisms.
• Skin and nail scrapings for culture and microscopy.
3.5.3. Histopathology is used when indicated, for example:2, 14
• Wound biopsy to identify pathological changes.
3.5.4. Diagnostic imaging is used when indicated, for example:1-3, 5, 8, 26-28
• Plain x-ray (e.g. fracture, gas gangrene and osteomyelitis).
• Magnetic resonance imaging (e.g. osteomyelitis).
• Bone scan (e.g. osteomyelitis if magnetic resonance imaging is
contraindicated).
• Computed tomography (e.g. soft tissue infection, osteomyelitis).
• Sinogram and fistulagram to identify wound tracking.
3.5.5. Vascular assessment is conducted when indicated, for example:2, 7, 14
• Palpating pulses.
• Ankle brachial pressure index (ABPI) for vascular status of lower limb.
• Toe brachial pressure index (TBPI)/toe pressure for vascular status of
foot.

Standard 3
• Duplex ultrasound for venous and arterial disease.

• Photoplethysmography for venous disease.
• Transcutaneous oxygen pressure for local tissue perfusion.
• Angiography for arterial disease.
3.5.6. Neurological foot assessment is conducted when indicated, for
example:7, 14, 29
• Assessment for autonomic neuropathy by palpation of foot to assess
for bounding foot pulses and increased skin temperature, observation
for dry cracked skin integrity and foot deformity.
• Assessment for peripheral sensory neuropathy, for example using
a10g or 5.07 Semmes-Weinstein monofilament to evaluate sensation
and a 128 Hz tuning fork or biothesiometer for assessment of vibration
perception.
• Assessment for peripheral motor neuropathy using a patella hammer
to evaluate patella and Achilles’ reflexes and muscle weakness.
3.5.7. Nutritional screening and, when indicated, a full nutrition assessment is
conducted, for example:1-3
• Use of screening and assessment tools that are reliable and valid and
appropriate to the individual (e.g. Mini Nutritional Assessment [MNA],
MNA® short form, Malnutrition Universal Screening Tool [MUST]).1
• Assessment of the quantity, quality and nutritional content of food
and fluid intake.
• Assessment of weight status, including weight history (e.g. weight loss
≥ 5% in 30 days or ≥ 10% in 180 days).1
• Anthropometric assessment, including:
o Height.
o Waist circumference.
o Waist to hip ratio.
o Objective estimates of subcutaneous fat (e.g. body mass index)
and skeletal muscle stores.
• Formulas such as the Harris-Benedict equation to measure and
evaluate Basal Metabolic Rate (BMR) or Basal Energy Expenditure
(BEE).1
• Hair and skin changes.
• Ability to eat, including any assistance or diet requirements (e.g.
thickened fluids or pureed food).
• Additional specific biochemical tests (e.g. albumin, transferrin, zinc or
vitamins).1
3.5.8. Cognitive screening and psychosocial assessment is conducted, for
example:30, 31

Standard 3
• Cognitive screening using tools that are reliable and valid (e.g.
Mini Mental State Examination [MMSE], Modified Mini Mental State
Examination [3MS], Cognitive Abilities Screening Instrument).32, 33
• Psychological screening using tools that are reliable and valid (e.g.
Hospital Anxiety and Depression Scale, Beck Depression Inventory,
Hamilton Anxiety Rating Scale).
• Wellbeing, quality of life, social and wound impact assessment using
valid and reliable tools for specific health populations (e.g. Short Form
36, World Health Organisation Quality of Life, Cardiff Wound Impact
Schedule, Chronic Venous Insufficiency Questionnaire).2, 3, 6, 34

A comprehensive and holistic assessment of the individual, their wound and the
wound healing environment is an integral component of wound prevention
and management. Assessment and diagnosis underpin decision-making in the
development and ongoing evaluation of an individualised plan to prevent wound
development and to promote healing of existing wounds.
Assessing the individual, the wound and the healing environment
A comprehensive assessment of the individual acknowledges the contribution of a

large range of intrinsic factors that influence both the risk of developing a wound
and the ability of the individual to heal. Comorbidities, nutrition status, vascular
status and infection all influence skin and tissue health and reparative processes.
Appropriate investigation of overall health allows the interprofessional team to
develop a management plan that will address underlying factors that influence the
risk of wounding and/or ability to heal.2, 3, 11
It is widely acknowledged that in addition to the physical factors that influence

the ability of the individual to heal, the cognitive and psychosocial status of the
individual are important contributory factors to healing, wellbeing and quality of
life for those who live with, or at risk of, a wound. Ascertaining the ability of the
individual to communicate and understand factors relating to their general health
and wound prevention and management is crucial in engaging the individual in
both the assessment process and in ongoing decision making and management
interventions. Assessment of multidimensional factors, including the individual’s
social support and engagement, psychological health and quality of life provides
context to that person’s resources, abilities to engage in potential interventions and
additional assistance they may require to prevent or manage wounds.2, 3, 11
Initial and ongoing wound assessment is critical to promotion of healing. Certain

characteristics of the wound can provide key indicators to the interprofessional team
as to the wound’s changing status and the success or otherwise of a management
plan. Accurate and well-documented assessment allows health care professionals
and health care workers to identify covert signs of infection (e.g. hypergranulation,
friable granulating tissue, wound breakdown or epithelial bridging)35-37 and act
accordingly. Regular documentation of wound dimension, appearance and
characteristics at each wound dressing change allows determination of wound
progress, which can provide an indication of effectiveness of treatment or suggest
potential complications that are hindering normal wound healing (e.g. biofilm).

Standard 3
The surrounding environment is crucial to wound healing, and strategies the

interprofessional team might implement when managing the wound and in
promotion of healing in general. Attention to the risk of infection from the environment
(e.g. from air borne contaminants, unclean surfaces or equipment, ventilation or
water sources) is most critical when the wound is exposed. Environmental factors
can influence the concordance of individuals with prevention and management
interventions, for example, in a warm or humid environment, compression stockings
or bulky wound dressings may impact on the individual’s comfort.2 Assessment of the
local environment in community settings may provide indicators to factors that could
influence healing (e.g. non-hygienic conditions, access to equipment, storage and
waste facilities, presence of pets).38-41
Assessment and measurement tools
The way in which a health assessment is conducted can influence the reliability
and relevance of the information that is collected. Best practice requires that
interprofessional team members and health care workers use assessment tools that
have been scientifically validated when undertaking clinical assessments. Validity
refers to the ability of an assessment tool or test to measure the factor that it purports
to be assessing. Reliability of an assessment tool or test refers to the ability of the
assessment strategy to produce the same result if it is administered repeatedly to the
same individual.42
Reliability and validity are important considerations because strong psychometric

qualities of the assessment tool ensure the diagnoses arising from the assessment are
based on accurate information. If the tools used to conduct an assessment have
strong validity and reliability there can be greater certainty that the interprofessional
team and health care workers are measuring the characteristics they have targeted,
and that any changes in the individual’s assessment results are not random.42
Selection of assessment tools should be individualised. Many assessment tools are

developed for specific populations, and may not be valid and reliable for measuring
the same criteria in a different population.42 For example, a tool designed to
measure severity of pain that has been developed for adults, may not have strong
psychometric qualities if it is used to measure pain in children or adults with cognitive
impairment. Where possible, assessment strategies should be selected based on
psychometric qualities, the individual’s characteristics (e.g. age, cognitive status,
health status and health literacy), the appropriateness of the items on the tool to
that individual, the individual’s and clinician’s preferences, resources available and
local policies and procedures.
Emerging and advanced wound assessment and measurement techniques
More advanced wound measurement technologies (e.g. digital photography,

digital software planimetry, 3D wound mapping) are becoming more accessible.7
Other digital technologies support telecommunications (e.g. telehealth) and have
improved the access of individuals in rural and remote areas to specialised wound
practitioner. It is important that the interprofessional team selects technology that
is scientifically demonstrated to provide accurate assessment, and that individual
members of the team receive education in training to ensure advanced wound
evaluation strategies are implemented accurately.
Wound assessment in recent times has been aided by techniques that allows for
more detailed evaluation of numerous skin and tissue characteristics.7 Research
has explored the use of physical markers (e.g. skin and tissue moisture, wound and

Standard 3
tissue temperature, and pressure), biochemical markers (e.g. pH and odour) and
molecular markers (e.g. proteases, DNA of micro-organisms, RNA, genes and their
function).1, 14, 43, 44 Advances in biomarker and molecular technology hold increasing
promise for more comprehensive healing assessment and diagnostics.45-47
References
(EPUAP), and Pan Pacific Pressure Injury Alliance (PPPIA), Prevention and Treatment of
Pressure Ulcers: Clinical Practice Guideline. 2014: Emily Haesler (Ed.) Cambridge Media:
Osborne Park, WA.
2. Australian Wound Management Association (AWMA) and New Zealand Wound Care
Society (NZWCS), Australia and New Zealand Clinical Practice Guideline for Prevention
and Management of Venous Leg Ulcers. 2012 Cambridge Media: Osborne Park, WA.
3. Australian Wound Management Association (AWMA), Pan Pacific Clinical Practice

4. Ousey, K. and L. Cook, Understanding the importance of holistic wound assessment.

Practice Nursing, 2011. 22(6): p. 308-14.
5. Chadwick, P. and J. McCardle, Assessing infected ulcers: a step-by-step guide. Journal

of Wound Care, 2015. 24(5 Suppl 2): p. 15-9.
6. Swindon, W.B. and G. north east Somerset Wound, Identification, diagnosis and treatment
of wound infection. Nursing Standard, 2011. 26(11): p. 44-8.
7. Mani, R., et al., Optimizing technology use for chronic lower-extremity wound healing: A
consensus document. The International Journal of Lower Extremity Wounds, 2016: p. 1-18.
8. Lipsky, B.A., et al., IWGDF guidance on the diagnosis and management of foot infections
in persons with diabetes. Diabetes Metabolism Research and Review, 2016. 32(Supp 1):
p. 45-74.
9. Ahn, C. and R.S. Salcido, Advances in wound photography and assessment methods.
Advances in Skin & Wound Care, 2008. 21(2): p. 85-95.
10. Benbow, M., Wound care: ensuring a holistic and collaborative assessment. British Journal
of Community Nursing, 2011: p. S6-16
11. Cornforth, A., Holistic wound assessment in primary care. British Journal of Community
Nursing, 2013. 18(12): p. S28-34.
12. Vowden, K., Defining, assessing and managing cavity wounds. Wounds UK, 2016. 12(1): p.
18-23.
13. Kerr, A., How best to record and describe wound exudate. Wounds UK, 2014. 10(2): p. 50-
7.
14. Lozano-Platonoff, A., et al., Assessment: Cornerstone in Wound Management. Journal of

the American College of Surgeons, 2015. 221(2): p. 611-20.
15. Stotts, N.A., et al., An instrument to measure healing in pressure ulcers: development and
validation of the pressure ulcer scale for healing (PUSH). Journals of Gerontology. Series
A, Biological Cciences and Medical Sciences, 2001. 56A(12): p. M795-99.
16. International Wound Infection Institute, Wound infection in clinical practice: A 2016
international consensus update. IN PRESS, 2016.

Standard 3
17. Carville, K., et al., STAR: A consensus for skin tear classification. Primary Intention 2007.
15(1): p. 18-28.
18. Korzendorfer, H., P. Scarborough, and H. Hettrick, Tissue destruction classification systems.
19. Game, F.L., Classification of diabetic foot ulcers. Diabetes Metabalism Research and
Review, 2016. 32(Supp 1): p. 186-94.
20. van Rijswijk, L., Measuring Wounds to Improve Outcomes. American Journal of Nursing,
2013. 113(8): p. 60-1.
21. Sibbald, G., et al., Optimizing the moisture managemen tightrope with wound bed
preparation 2015. Advances in Skin & Wound Care, 2015. 28(10): p. 466-76.
22. Okan, D., et al., The role of moisture balance in wound healing. Advances in Skin &
Wound Care, 2007. 20(1): p. 39-55.
23. Gardner, S., et al., Diagnostic validity of three swab techniques for identifying chronic
wound infection. Wound Repair & Regeneration, 2006. 14: p. 548-57.
24. Angel, D.E., et al., The clinical efficacy of two semi-quantitative wound-swabbing
techniques in identifying the causative organism(s) in infected cutaneous wounds.
International Wound Journal, 2011. 8(2): p. 176-85.
25. Fierheller, M. and R.G. Sibbald, A clinical investigation into the relationship between
increased periwound skin temperature and local wound infection in patients with chronic
leg ulcers. Advances in Skin & Wound Care, 2010. 23(8): p. 369-81.
26. Teh, J., T. Berendt, and B. Lipsky, Investigating suspected bone infection in the diabetic
foot. British Medical Journal, 2010. 340: p. 415-9.
27. Schwegler, B., et al., Unsuspected osteomyelitis is frequent in persistent diabetic foot ulcer
and better diagnosed by MRI than by 18F-FDG PET or 99mTc-MOAB. Journal of Internal
Medicine, 2007. 263: p. 99-106.
28. Bires, A.M., B. Kerr, and L. George, Osteomyelitis: An overview of imaging modalities.
Critical Care Nursing Quarterly, 2015. 38(2): p. 154-164.
29. Boulton, A.J., et al., Comprehensive foot examination and risk assessment: a report of
the task force of the foot care interest group of the American Diabetes Association with
endorsement by the American Association of Clinical Endocrinologists. Diabetes Care,
2008. 31(8): p. 1679-85.
30. Langemo, D.K., Psychosocial aspects in wound care. Quality of life and pressure ulcers:
what is the impact? Wounds, 2005. 17(1): p. 3-7.
31. Boutoille, D., et al., Quality of life with diabetes-associated foot complications: comparison
between lower-limb amputation and chronic foot ulceration. Foot & Ankle International,
2008. 29(11): p. 1074-8.
32. Cullen, B., et al., A review of screening tests for cognitive impairment. Journal of
NeurologyNeurosurgery and Psychiatry, 2007 78(8): p. 790-9.
33. Schultz-Larsen, K., R.K. Lomholt, and S. Kreiner, Mini-mental status examination: a short
form of MMSE was as accurate as the original MMSE in predicting dementia. Journal of
Clinical Epidemiology, 2007. 60: p. 260-7.
34. Persoon, A., et al., Leg ulcers: a review of their impact on daily life. Journal of Clinical
Nursing, 2004. 13(3): p. 341-54.

Standard 3
35. World Union of Wound Healing Societies (WUWHS), Principles of best practice: Wound
infection in clinical practice. An international consensus. 2008, MEP Ltd: London.
36. Gardener, S.E. and F.A. Frantz, Wound bioburden and infection-related complications in
diabetic foot ulcers. Biological Research for Nursing, 2008. 10(1): p. 44-53.
37. Gardner, S.E., R.A. Frantz, and H. Park, The interrater reliability of the clinical signs and
symptoms checklist in diabetic foot ulcers. Ostomy Wound Management, 2007. 53(1):
p. 46-51.
38. Grossman, S. and D.D. Mager, Managing the threat of methicillin-resistant Staphylococcus
aureus in home care. Home Health care Nurse, 2008. 26(6): p. 356-66.
39. Hart, S., Using an aseptic technique to reduce the risk of infection. Nursing Standard,
2007. 21(47): p. 43-8.
40. Pegram, A. and J. Bloomfield, Wound care: principles of aseptic technique. Mental
Health Practice, 2010. 14(2): p. 14-8.
41. Swanson, J. and A. Jeanes, Infection control in the community: a pragmatic approach.
British Journal of Community Nursing, 2011. 16(6): p. 282-8.
42. DeVon, H.A., et al., A psychometric toolbox for testing validity and reliability. Journal of
Nursing Scholarship, 2007. 39(2): p. 155-64.
43. Serena, T.E., et al., Defining a new diagnostic assessment parameter for wound care:
Elevated protease activity, an indicator of nonhealing, for targeted protease-modulating
treatment. Wound Repair & Regeneration, 2016. 24(3): p. 589-95.
44. Dargaville, T.R., et al., Sensors and imaging for wound healing: A review. Biosensors and
Bioelectronics, 2013. 41: p. 30-42.
45. Mohd, S.J., et al., Cellular events and biomarkers of wound healing. Journal of Plastic
Surgery, 2012. 45(2): p. 220-8.
46. Patel, S., A. Maheshwari, and A. Chandra, Biomarkers for wound healing and their
evaluation. . Journal of Wound Care, 2016. 25(1): p. 46-55.
47. Snyder, R., et al., Using a diagnostic tool to identify elevated protease activity levels in
chronic and stalled wounds: A consensus panel discussion. Ostomy /Wound Management,
2011. 57(12): p. 36-46.

Standard 4
STANDARD 4
CLINICAL DECISION MAKING: PLANNING AND PRACTICE
Wound prevention and management is practised according
to the best available evidence for optimising outcomes for the
individual, their wound and their healing environment.
Rationale
The goal of wound management is to prevent wounding and to maximise healing
potential. Strategies to both prevent and manage wounds are guided by assessment
outcomes and selected according to evidence and efficacy in meeting the goals
of care.
Criteria
Scope of practice includes:
4.1. Goals of care are established with the individual, the interprofessional team,
health care workers and informal carers and reflect evidence-based practice
and the preferences of the individual.1, 2
Evidence Criteria
4.1.1. Goals of care are established in conjunction with the individual and
interprofessional team.
4.1.2. Goals of care are clearly defined and documented.
4.1.3. Goals of care address optimisation of healing and the individual’s

capacity to heal.2
4.1.4. Goals of care address conservative/palliative wound management

where appropriate.
4.2. Strategies to prevent wound development are implemented according to

comprehensive individual assessment.3-12
Evidence Criteria
4.2.1. A wound prevention plan appropriate to the individual is documented
and includes:
• Preventive skin care.
• Application of compression therapy for chronic venous insufficiency.

Standard 4
• Strategies to manage pressure, friction and shear.

• Strategies to manage skin moisture, including incontinence.
• Strategies to avoid trauma.
• Strategies to maximise nutrition status.
• Use of protective footwear and off-loading devices.
• Referral for assessment of skin lesions.
4.3. The ability of the individual to heal is optimised.
Evidence Criteria
4.3.1. Systemic factors and comorbidities that may impair wound healing are
managed and optimised.1, 13, 14
4.3.2. The individual receives adequate nutrition and hydration, with

consideration to nutritional requirements for optimal wound healing and
correction of nutritional deficits.1, 13
4.3.3. Medications that impair wound healing are reviewed with consideration
to benefit versus risk.13
4.3.4. Cessation of smoking is promoted.13
4.3.5. Mobility, activity and exercise as tolerated are encouraged.3, 5
4.3.6.
Psychosocial factors that may hinder optimal wound healing
are addressed including mental health conditions and access to
psychosocial support.1, 15
4.4. The type of aseptic technique selected when performing a wound dressing
procedure is appropriate to the individual, their wound and their healing
environment.16
Evidence Criteria
4.4.1. Selection of surgical aseptic technique or standard aseptic technique is
consistent with policies and procedures of the service provider.17
4.4.2. Surgical aseptic technique is implemented when performing a wound
dressing procedure that:
• Is technically complex.18-21
• Penetrates a sterile body cavity (e.g. nephrostomy or central venous

line).
• Involves an extensive wound.18

Standard 4
• Is anticipated to be a longer procedure (i.e. > 20 minutes of wound

exposure).18, 19
• Requires insertion of dressing material or a device into a wound sinus

or cavity where the base cannot be entirely visualised.
4.4.3. Surgical aseptic technique is implemented when managing a wound in

the operating theatre.17, 18, 20
4.4.4. Standard aseptic technique is implemented when the wound healing
environment is not compromised and the criteria for surgical aseptic
technique outlined in 4.4.2. to 4.4.3. is not demonstrated. For example,
standard aseptic technique may be implemented when:
• The procedure is technically simple.18
• The procedure is anticipated to be shorter in duration (i.e. < 2o minutes
of wound exposure).18, 20, 21
4.5. Aseptic techniques are performed in a manner consistent with best available
evidence.
Evidence Criteria
4.5.1. Performance of surgical aseptic technique or standard aseptic
technique is consistent with policies and procedures of the service
provider.22
4.5.2. Appropriate hand hygiene is attended before, during and after wound
dressing procedures, regardless of the use of gloves.18, 19, 21, 23
4.5.3. Exposure to airborne contaminants is avoided during wound dressing

procedures.21
4.5.4. Surgical aseptic technique is performed using, sterile gloves and a

critical aseptic field.17-19, 24
4.5.5. Standard aseptic technique is performed using non-sterile gloves and a

general aseptic field.17, 25
4.5.6. Contaminated waste is disposed of appropriately at the completion of

a wound dressing procedure.18, 19, 21
4.6. Showering or washing of approximated incisions and lacerations18, 26-31 and

chronic wounds28, 32, 33 is only performed after a risk assessment and in a manner
consistent with best available evidence.
Evidence Criteria
4.6.1. The showering or washing of approximated incisions18, 26-31 or chronic
wounds28, 32, 33 is consistent with policies and procedures of the service
provider.22

Standard 4
4.6.2. If the showering of approximated incisions or lacerations18, 26-31 or chronic

wounds28, 32, 33 is assessed as appropriate, potable water is used.
4.6.3. If washing of chronic wounds28, 32, 33 is assessed as appropriate, potable

water and non-sterile gloves are used.
4.7. Wound bed tissue is protected and optimised for wound healing.
Evidence Criteria
4.7.1. Devitalised or infected tissue is removed from the wound bed using an
appropriate cleansing or debridement method with consideration to:1, 5,
14, 34, 35
• Wound assessment outcomes.
• Arterial insufficiency.
• Spreading or systemic infection.
• Uncontrolled comorbidities.
• Access to sterile equipment.
• Clinical competence.
4.7.2. Foreign bodies are removed from the wound bed.34
4.7.3. Aggressive wound cleansing is avoided, except when the goal of care
is debridement.5, 36
4.7.4. Known allergens and agents that are toxic to tissue are avoided.35-37
4.7.5. Products, pharmaceuticals, devices and interventions that traumatise
the wound bed are avoided.36, 38, 39
4.7.6. Products, pharmaceuticals, devices and/or irrigation are avoided in
sinus tracking for which dimensions cannot be visualised without further
investigations.
4.7.7. Products, pharmaceuticals, drainage tubes or devices inserted into a

sinus are in one continuous piece, are able to be visualised and are
secured at the wound surface.40
4.7.8. Products, pharmaceuticals, drainage tubes or devices inserted into the

wound are documented and removed in entirety.
4.7.9. The wound bed, peri wound/surrounding tissues are protected from
pressure, shear and friction through:3, 5, 11, 41
• Avoiding tight or excessive packing that may damage the wound
bed.
• Using preventive strategies (e.g. prophylactic dressings) when medical
devices (e.g. drainage tubes) are in use.

Standard 4
• Using pressure offloading strategies including repositioning, pressure

redistributing support surfaces and heel devices, particularly for
plantar foot wounds and pressure injuries.
• Using appropriate repositioning techniques to avoid shearing.
4.8. Wound-related infection and cross infection are prevented and managed.
Evidence Criteria
4.8.1. Adequate and regular hand hygiene is practised and is consistent with
universal precautions.21, 23
4.8.2. Personal protective equipment (e.g. plastic apron, mask and goggles)
is used when there is a risk of contamination to the individual or the
interprofessional team or health care workers.21, 42-44
4.8.3. The individual’s immune response is optimised through management of

other health conditions and nutritional deficits.1, 3-5
4.8.4. The risk of wound bed contamination by exogenous microorganisms is
reduced through:1, 39
• Using appropriate aseptic technique.
• Performing wound dressing procedures with appropriate frequency.
• Performing adequate wound cleansing.
• Performing adequate debridement using an appropriate technique

for the wound bed condition.
4.8.5. Products, pharmaceuticals, devices and interventions that are used are
supported by evidence.3-5, 40
4.8.6. Use of systemic antibiotics (and, rarely, topical antibiotics) is consistent

with the policies and procedures of service providers, relevant guidelines,
and the principles underpinning antibiotic stewardship.14, 45-47
4.8.7. When clinical indicators of biofilm, covert or overt signs of local wound
infection are present, appropriate management is initiated, for
example:1, 3-5
• Frequent and adequate cleansing and debridement of the wound

bed.
• Prudent and discriminate use of tissue friendly topical antiseptic

products (e.g. cadexomer iodine, silver products, wound-grade
honey, polyhexamethylene biguanide [PHMB]).
• Selection of topical therapies made with consideration of the

evidence and the risk of adverse effects.

Standard 4
4.8.8. When signs and symptoms of spreading infection and/or systemic

infection and/or osteomyelitis are present, appropriate management is
initiated, for example: 3-5, 47, 48
• Consideration of pathological and radiological investigations (e.g.
semi-quantitative swab culture, wound biopsy, peptide nucleic
acid fluorescent in situ hybridisation [PNA-FISH], light and electron
microscopy, plain x-ray, magnetic resonance imaging, bone scan)
and clinical assessment outcomes in determining causative organisms.
• Prudent and discriminate use of tissue friendly topical antiseptics in

combination with targeted systemic antibiotic therapy.
• Appropriate referral to interprofessional team members (e.g. infectious

diseases team).
4.9. An optimal wound moisture balance is maintained and the peri-wound/

surrounding tissue is protected from moisture.2-5, 35, 49-55
Evidence Criteria
4.9.1. A moist wound healing environment is promoted, except in the following
situations where this is clinically contraindicated:1, 3, 5, 34, 54
• In the presence of dry, stable eschar with insufficient blood flow to the
affected body part to support wound healing and immune responses
to infection.
• In conservative wound management when healing is not a realistic

goal and eschar protects underlying vascular structures and tissues
against bleeding or infection.
4.9.2. Products, pharmaceuticals, devices and interventions are selected

based on their ability to maximise moisture balance while adequately
managing exudate.1, 2, 34, 50, 54
4.9.3. Products, pharmaceuticals, devices and interventions that desiccate

the wound bed and/or surrounding tissue are avoided.
4.9.4. Wound dressings are changed with sufficient frequency to prevent

maceration from wound exudate.2, 35
4.9.5. Drainage of wound exudate from the wound bed is promoted (e.g.
avoid excessive or tight wound packing).
4.10. An optimal wound temperature is maintained when performing a wound

dressing procedure.54, 56
Evidence Criteria
4.10.1. Wound exposure is minimised.57

Standard 4
4.10.2. Exposure of the wound to cool temperatures, including cooled

products, solutions, wound dressings, pharmaceuticals, therapies or
devices is avoided.57, 58
4.10.3.
Cleansing solutions are warmed to body temperature before
application to the wound bed.42, 59, 60
4.10.4. Extremes in body and intact skin temperatures are prevented by:5, 58, 61
• Limiting skin contact with plastic bed and pillow protectors and
plastic lined garments.
• Avoiding overheating with clothing, bed linen or heating devices.
• Promoting adequate hydration.
• Maintaining a stable and comfortable environmental temperature.
4.10.5. Advice on maintaining normal body and skin temperature is provided.
4.11. An optimal wound pH is maintained when performing a wound dressing

procedure and skin care.56, 62-67
Evidence Criteria
4.11.1. A neutral or slightly acidic wound pH is promoted by avoiding the use

of alkaline soaps, cleansers and other agents.3, 5
4.11.2. Desiccation of the wound bed/peri wound, which increases wound

alkalinity, is avoided.65
4.12. Potential and actual impact of wound-related pain is minimised.
Evidence Criteria
4.12.1. Causative factors of pain (e.g. infection, activities or devices) are

identified and managed.1, 3-5, 68-71
4.12.2. Wound dressings, pharmaceutical products and devices that minimise

trauma on application and removal are selected.1, 5, 35, 72-74
4.12.3. Non-pharmacological adjunctive interventions to prevent, minimise

and manage wound-related pain are implemented and regularly
reviewed.1, 3-5, 72, 73, 75-78
4.12.4. When non-pharmacological interventions are insufficient to control

pain, an analgesia regimen is prescribed, implemented and regularly
reviewed.1, 3-5, 72, 79

Standard 4
4.13. Innovations for stimulating wound healing, including biophysical technologies

and treatments that alter the biology of the wound, are considered with respect
to the evidence base demonstrating their efficacy in similar populations and
the potential risks of treatment.14, 34
Evidence Criteria
4.13.1. Biophysical technologies that purport to stimulate wound healing (e.g.
electrical stimulation, ultrasound and electromagnetic treatment) are
used as adjunctive therapies, and do not replace accepted standards
of wound management.
4.13.2. Therapies that purport to change the biology of the wound (e.g.
biological dressings, growth factors and topical oxygen) are used
as adjunctive therapies, and do not replace accepted standards of
wound management.
4.14. Products, pharmaceuticals and devices are used in accordance with

licensing acts, regulations and manufacturer guidelines and their integrity is
maintained.80, 81
Evidence Criteria
4.14.1. Products, pharmaceuticals and devices are used for the indications
approved by the Therapeutic Goods Administration or, when used as a
component of a research protocol, with appropriate ethics approval.
4.14.2.
Products, pharmaceuticals and devices are used, stored and
maintained according to the manufacturer’s instructions.
4.14.3. Products, pharmaceuticals and devices are changed or replaced as

frequently as required to perform their designated function.
4.14.4. Compatibility and efficacy is evaluated when using products in

conjunction with one another.

Goals of care
Developing goals of care collaboratively and with input from the individual and their
informal carers is intrinsic to successful wound prevention and management. Goals
of care should be specific, measurable, attainable, relevant and time bound. They
should consider the individual’s specific circumstances and the resources available.
Goals that are measurable and time bound can be tracked and reviewed to
determine the efficacy of interventions and review the management plan.82
In individuals for whom ability to heal is significantly compromised (e.g. palliative

care, inadequately perfused wounds, distal gangrene), conservative wound
management is an option.2, 35, 83 Management of symptoms that concern the
individual (e.g. pain and odour) and prevention of further skin breakdown are
appropriate interventions for maintenance of non-healing wounds. Aggressive

Standard 4
sharp debridement is not appropriate in palliative care or for wounds without the
ability to heal.2
Evidence based practice
Development of a prevention and management plan is underpinned by the

individual’s preferences, wound and/or risk assessment and the established goals of
care. Prevention and management decisions should ideally be based on scientific
evidence that provides objective data indicating the efficacy of the intervention.
Maintaining a scientific and evidence-based approach when making clinical
decisions regarding wound management and prevention is associated with superior
clinical outcomes and more cost-effective care.84 However, it is important that
evidence is not used in isolation. A body of evidence on specific interventions requires
interpretation and evaluation by the care team and individual team members
to determine its appropriateness to the individual e.g. personal preferences), the
interprofessional team (e.g. skill level) and the local setting (e.g. resources).84, 85
Advances in knowledge, technologies and emerging wound therapies are ongoing,

and the interprofessional team and health care workers are advised to seek
best evidence for their implementation. Systematic reviews and clinical practice
guidelines are sources of evidence that can provide comprehensive and concise
guidance for health care professionals and health care workers. These sources
generally compile the best available evidence for interventions and develop
recommendations for best clinical practice based on the strength of the body
of scientific evidence. However, as highlighted in many wound prevention and
management guidelines,3-5, 86 the current evidence base for many wound prevention
and management strategies is limited in quality and/or quantity, and the availability
of new evidence is ongoing.85 The interprofessional team and health care workers
therefore have an obligation to maintain a contemporary knowledge base and to
develop skills in evaluating and translating evidence into relevant clinical practice
that is applicable to specific individuals in their care.87
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preparation 2015. Advances in Skin & Wound Care, 2015. 28(10): p. 466-76.

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6. Langer, G. and A. Fink Nutritional interventions for preventing and treating pressure ulcers.
Cochrane Database of Systematic Reviews, 2014. CD003216.pub2.

Standard 4
7. Carville, K., et al., The effectiveness of a twice-daily skin-moisturising regimen for reducing
the incidence of skin tears. International Wound Journal, 2014. 11(4): p. 446-53.
8. Kottner, J., A. Lichterfeld, and U. Blume-Peytavi, Maintaining skin integrity in the aged: a
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Foot Journal, 2009. 12(3).

Standard 4
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Trauma Nursing, 2014. 18(3): p. 119-121.
40. Dumville Jo, C., et al. Hydrogel dressings for treating pressure ulcers. Cochrane Database
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43. Grossman, S. and D.D. Mager, Managing the threat of methicillin-resistant Staphylococcus
aureus in home care. Home Healthcare Nurse, 2008. 26(6): p. 356-66.
44. Preston, R.M., Aseptic technique: evidence-based approach for patient safety. British
Journal of Nursing, 2005. 14: p. 540-46.

Standard 4
45. Australian Government Department of Health and Ageing and Australian Government
Department of Agriculture, Responding to the Threat of Anitiobitic Resitance: Australia’s
First National Antimicrobial Resistence Strategy 2015-2019. 2015, Australian Government:
http://www.health.gov.au/.
46. Australian Commission on Safety and Quality in Health Care, National Safety and Quality
47. Lipsky, B.A., et al., IWGDF guidance on the diagnosis and management of foot infections
in persons with diabetes. Diabetes Metabolism Research and Review, 2016. 32(Supp 1):
p. 45-74.
48. Høiby, N., et al., ESCMID* guideline for the diagnosis and treatment of biofilm infections
2014. Clinical Microbiology and Infection, 2015. 21: p. S1-25.
49. Ousey, K. and M.G. Rippon. Hydration, Its Role In Wound Healing. in Wounds UK Annual
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-%20role%20in%20wound%20healing%20poster%20-%20version%205%20%28edit%29.pdf.
50. Powers, J.G., et al., Wound healing and treating wounds: Chronic wound care and
management. Journal of the American Academy of Dermatology, 2016. 74(4): p. 607-25.
51. Snyder, R.J., C. Fife, and Z. Moore, Components and quality measures of DIME (devitalized
tissue, infection/inflammation, moisture balance, and edge preparation) in wound care.
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52. Winter, G., Formation of the scab and the rate of epithelialization of superficial wounds in
the skin of the domestic pig. Nature, 1962. 193: p. 293-4.
53. Parnham, A., Moist wound healing: does the theory apply to chronic wounds? Journal of
Wound Care, 2002. 11(4): p. 143-6.
54. Benbow, M., Exploring the concept of moist wound healing and its application in practice.
British Journal of Nursing, 2008. 17(15): p. S4-16.
55. Jones, J., Winter’s concept of moist wound healing: a review of the evidence and impact
on clinical practice. Journal of Wound Care, 2005. 14(6): p. 273-6.
56. Kruse, C.R., et al., The external microenvironment of healing skin wounds. Wound Repair
& Regeneration, 2015. 23(4): p. 456-64.
57. McGuiness, W., E. Vella, and D. Harrison, Influence of dressing changes on wound
temperature. Journal of Wound Care, 2004. 13: p. 383-5.
58. Tweed, C.A., Review of the literature examining the relationship between temperature
and infection in surgical wound healing. Primary Intention, 2003. 11(3): p. 119-23.
59. Gannon, R., Wound cleansing: sterile water or saline? Nursing Times, 2007. 103(9): p. 44-6.
60. Schremmer, R.D., New concepts in wound management. Clinical Pediatric Emergency
Medicine, 2004. 5(4): p. 239-45.
61. Reger, S., V. Ranganathan, and V. Sahgal, Support surface interface pressure,
microenvironment, and the prevalence of pressure ulcers: an analysis of the literature.
Ostomy Wound Management, 2007. 53(10): p. 50-8.
62. Prabhu, V., et al., Does wound pH modulation with 3% citric acid solution dressing help in
wound healing: A pilot study Saudi Surgical Journal, 2014. 2(2): p. 38-46.
63. Percival, S.L., et al., The effects of pH on wound healing, biofilms, and antimicrobial
efficacy. Wound Repair & Regeneration, 2014. 22(2): p. 172-86.

Standard 4
64. Greener, B., et al., Proteases and pH in chronic wounds. Journal of Wound Care, 2005. 14:
p. 59-61.
65. Rushton, I., Understanding the role of proteases and pH in wound healing. Nursing
Standard, 2007. 21(32): p. 68-72.
66. Rodgers, A. and L. Watret, The role of pH modulation in wound bed preparation. Diabetic
Foot Journal, 2005. 8(3): p. 154.
67. Schneider, L.A., et al., Influence of pH on wound-healing: a new perspective for wound-
therapy? Archives of Dermatological Research 2007. 298(9): p. 413-20.
68. Mudge, E.J., et al., Patients’ experience of wound-related pain: an international

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69. Taverner, T., S.J. Closs, and M. Briggs, The journey to chronic pain: a grounded theory
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Wounds UK 2008. 4(2): p. 14-22.
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International Wound Journal, 2007. 4(S1): p. 4-15.
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78. Kim, J.Y., N.K. Kim, and Y.J. Lee, A descriptive study of Korean nurses’ perception of pain
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80. Therapuetic Goods Administration, Australian Regulatory Guidelines for Medical Devices
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Metabolism Research and Review, 2008. 24(Supp 1): p. S106-9.

Standard 4
83. Langemo, D.K., et al., Evidence-based guidelines for pressure ulcer management at the
end of life. International Journal of Palliative Nursing, 2015. 21(5): p. 225-32.
84. Brolmann, F.E., et al., Evidence-based decisions for local and systemic wound care. British
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87. Gonzales, R., et al., Increasing the translation of evidence Into practice, policy, and public
health improvements: A framework for training health professionals in implementation
and dissemination science. Acad Med., 2012 87(3): p. 271-278.

Standard 5
STANDARD 5
DOCUMENTATION
Documentation will provide a legal, comprehensive,
chronological record of assessments and progress, investigations
of the individual’s wound and risk of wounding, wound
management and/or prevention plans, and the outcome of care.
Rationale
Accurate, comprehensive and chronological health records promote the safety of
the individual, continuity of care delivery and ability to determine if the care plan is
effectively meeting the goals of care. Maintenance of health records in an accurate
and clear manner is a legal requirement that protects the individual, their informal
carer and the interprofessional team.
Criteria
Appropriate documentation includes:
5.1. Maintenance of a legible health record (e.g. health history and wound
management plan) that meets legislative, regulatory and service provider
requirements.
Evidence Criteria
5.1.1. The service provider has a documentation policy detailing the way in
which health and wound information will be collected and stored.
5.1.2. Handwritten records are legible and interprofessional team members

complete each health record entry with their name, designation,
signature and date.
5.1.3. Electronic records (e.g. wound assessments) are stored in a manner

consistent with privacy legislation (including records stored by offshore
third party service providers) and are backed up on a regular basis.1, 2
5.1.4. Records are maintained, stored and transferred according to legislative,

regulatory and service provider requirements.1-7
5.1.5. Notification of transfer of records is given to individuals in accordance

with local legislation.3-5, 8
5.1.6. Old health records are destroyed in a secure manner.3-6, 8

Standard 5
5.1.7. Documentation systems are maintained in a format that facilitates audit,

research and evaluation of care.7, 9-14
5.1.8. Health records associated with wound prevention and management

are provided to the new interprofessional team if the individual transfers
to a new health care service, with the consent of the individual.
5.2. Documented consultation with the individual and their informal carer regarding
the use of their health information.
Evidence Criteria
5.2.1. The individual and/or their informal carer are provided with information
relating to collection of health-related information and to whom access
to documentation is given.2
5.2.2. Informed consent is obtained for performance of clinical interventions.15, 16
5.2.3. Informed consent is obtained for wound assessments or management

reviews performed via telehealth.
5.2.4. Informed consent is obtained prior to the recording and use of wound
images.16
5.3. The individual’s health record is documented comprehensively, chronologically

and accurately.
Evidence Criteria
5.3.1. The individual’s health record contains documented wound-related
assessment; including:9, 14, 17, 18
• Comprehensive assessment of the individual, the wound and the
environment.
• Diagnostic investigations and results.
• Individual’s expectations.
• Long and short term goals of care.
• The individual and their informal carer’s preference, ability and
willingness to participate in care decisions and interventions.15
5.3.2.
The individual’s health record contains documented wound
management planning, including:
• Evidence of interprofessional communication and collaborative
care.15, 19
• Evidence that the individual and his/her informal carer receive
information about care options in a manner that is considerate of
their age, cognitive status, health literacy and culture that is used in
care planning decisions.15, 18

Standard 5
• Documented care decisions and management plan that includes

evidence based interventions to manage the individual and the
wound.14, 18, 19
5.3.3.
The individual’s health record contains documented review and
evaluation of wound management and progress toward goals of care,
including:14, 18
• Wound healing and health outcomes (e.g. pain management,
management of infection, psychosocial outcomes).
• Any adverse effects associated with management.
• Any changes to the wound prevention and/or management plan,
including rationales.

Documentation of wound prevention and management is important from a
variety of perspectives. The individual’s health record details the efficacy of the
management plan and the progress toward care goals. It is a method through
which the interprofessional team and health care workers can communicate with
each other regarding the individual’s progress and any issues that may arise in
care delivery. Documentation also records interprofessional referrals and forms an
ongoing legal account of the care provided.
Maintaining legible and lawful health records
Legible records are important to ensure continuity of care, and are required from
a medico-legal perspective. Record entries should be signed and dated, and the
identity of the team member completing the record should be legible. Documentation
should be accurate, specific and use only standard abbreviations. Documented
health records should not be altered or erased. If changes are required, additional
information can be added to a record (and dated) or information can be deleted
by ruling through the mistaken entry and initialling and dating changes.20, 21 These
principles promote continuity of care and protect the individual and interprofessional
team and health care workers in the event of complaints or legal action.14
Under Australian Privacy Principle One2 health service providers are required to
clearly express how health-related information will be collected and managed. This
information should be available for the individual, informal carers and members
of the interprofessional team and health care workers. The kind of information
that should be included in the health service’s privacy policy includes the kind of
information that is collected and how it is used, for what purposes information is
disclosed to other people or service providers, the process for an individual to access
their documented medical record, and how individuals can make a complaint
if their privacy is breached.2 Other Commonwealth and State legislation includes
guidance on ways in which medical records must be stored, who may access
records, the length of time records must be stored and how records are transferred
or destroyed.1, 3-6, 8, 22
Documenting patient decision making
The right to engage in decisions regarding one’s care is a foundation health care
principle. Informed consent requires the individual to have engaged in an informed

Standard 5
decision making process with the support of the interprofessional team and his or her
informal carers. Counselling the individual about the role and outcome of assessment
of a wound or the risk of wounding and options for care based on the assessment
should be thoroughly documented in the individual’s health record, including the
education with which the individual was provided, the individual’s goals for care,
alternative care strategies that have been discussed, and the choices the individual
has made with respect to ongoing care planning and delivery. This documentation
serves as a both a legal record, and communication to the interprofessional team
and health care workers regarding the education and consultation that has been
undertaken.15
References
1. Australian Capital Territory Legislative Assembly. Health Records (Privacy and Access) Act
1997 - Schedule 1 The Privacy Principles; Principle 4.1: Storage, security and destruction
of personal health information - safekeeping requirement (3). 1997. Available at: www.
legislation.act.gov.au/a/1997-125/default.asp.
2. Commonwealth Government of Australia. Privacy Act 1988 - Schedule 1, Australian

Privacy Principles. 1988: Available at: http://www.comlaw.gov.au/Series/C2004A03712.
3. New South Wales Government. Health Practitioner Regulation (New South Wales)
Regulation 2010 - Schedule 2 Records kept by medical practitioners and medical
corporations in relation to patients, in 2010 No 333. 2010: Available at: www.legislation.
nsw.gov.au/sessionalview/sessional/sr/2010-333.pdf.
4. New South Wales Government. Health Records and Information Privacy Act 2002
Retention of health information: health service providers in No 71,s25 2002: Available at:
www.legislation.nsw.gov.au/fullhtml/inforce/act+71+2002+FIRST+0+N.
5. Victorian Government. Health Records Act 2001 – Schedule 1, Section 19 The Health
Privacy Principles, in 4.2. 2001: Available at: www.austlii.edu.au/au/legis/vic/consol_act/
hra2001144/sch1.html.
6. Victorian Government. Health Records Act 2001, in Section 95 (2). 2001: Available at:
www.austlii.edu.au/au/legis/vic/consol_act/hra2001144/s95.html.
7. Murphy R. Legal and practical impact of clinical practice guidelines on mursing and
medical practice. Advances in Wound Care, 1996. 9(5): 31-4.
1997: Schedule 1: The Privacy Principles: Principle 4.2: Storage, security and destruction of
personal health information - register of destroyed or transferred records. 1997: Available
at: www.legislation.act.gov.au/a/1997-125/default.asp.
9. Hess CT. Mapping documentation to support your work performed. Advances in Skin &
Wound Care, 2011. 24(11): 536.
10. Hess CT. The art of auditing documentation. Advances in Skin & Wound Care, 2011.
24(10): 488.
11. Hess CT. Wound care documentation, compliance, and revenue checklist. Advances in
Skin & Wound Care, 2014. 27(3): 144.
12. Hess CT. Auditing wound care documentation. Advances in Skin & Wound Care, 2015.
28(5): 240.

Standard 5
13. Hess CT. The art of skin and wound care documentation. Advances in Skin & Wound
Care, 2005. 18(1): 43-55.
14. Kinnunen UM, Saranto K, Ensio A, Iivanainen A, Dykes P. Developing the standardized
wound care documentation model: A delphi study to improve the quality of patient
care documentation. Journal of Wound, Ostomy and Continence Nursing, 2012. 39(4):
397-407.
15. Choudry M, Latif A, Hamilton L, Leigh B. Documenting the process of patient decision
making: a review of the development of the law on consent. 2015. 3(2): 109–13
16. Sharpe K, Baxter HWC. Obtaining consent in wound care: What are the key issues?
Journal of Wound Care, 2002. 11(1): 10-2.
17. Hess CT. Mapping documentation to support your work performed: Part 2. Advances in
Skin & Wound Care, 2011. 24(12): 584.
18. Brown G. Wound documentation: Managing risk. Advances in Skin & Wound Care, 2006:
155-67.
19. Hess CT. Mapping documentation to support your work performed: Part 3. Advances in
Skin & Wound Care, 2012. 25(1): 48.
20. Johnson LJ. Legibility, accuracy, specificity vital in records. Medical Economics, 2010.
May.
21. Butcher M. Wound care and word care go hand in hand. British Journal of Nursing, 2013.
22(15): S3.
22. Victoria Government. Health Records Act 2001 - Schedule 1, Section 19 The Health Privacy
Principles, Principle 10 - Transfer or closure of the practice of a health service provider.
2001: Available at: www.austlii.edu.au/au/legis/vic/consol_act/hra2001144/sch1.html.

Standard 6
STANDARD 6
EDUCATION
Opportunities for advancing self-knowledge and skills in wound
prevention and management are maximised.
Rationale
Engaging in continuous professional development promotes knowledge of the
latest wound prevention and management practices and enables adoption of an
evidence based approach to clinical care.
Education of the individual and their informal carer maximises their ability to
participate in care decisions and activities.
Criteria
Maximised education opportunity includes:
6.1. Learning needs of members of the interprofessional team and health care
workers in wound prevention and management are identified.1-6
Evidence Criteria
6.1.1. A continuous professional development plan is developed and reviewed
annually.
6.2. Opportunities for advancing knowledge and skills in wound prevention and
management are undertaken.1-5
Evidence Criteria
6.2.1. Evidence-based educational strategies relevant to individual needs are
undertaken.
6.3. The learning needs of the interprofessional team are supported.3, 7-9
Evidence Criteria
6.3.1. Individual team members demonstrate positive role modelling.
6.3.2. Individual team members share their knowledge and skills with the
interprofessional team and health care workers.

Standard 6
6.4. The interprofessional team regularly identifies, critiques, implements and

evaluates evidence for wound prevention and management.
Evidence Criteria
6.4.1.
The interprofessional team has access to contemporary wound
prevention and management research and best practice.
6.4.2. The interprofessional team has collaborative processes through which

new evidence is critiqued and introduced into clinical practice.
6.4.3. The service provider supports adoption of new practice.
6.4.4. New evidence is implemented in the care of individuals with or at risk of

wounds and outcomes are regularly reviewed.
6.5. Learning needs of the individual and their informal carers are supported.10-14
Evidence Criteria
6.5.1. Learning needs of the individual and their informal carers are assessed
and documented.
6.5.2. Relevant learning opportunities are provided to individuals and their

informal carers in a manner that is appropriate to age, cognitive status,
health literacy, language and culture.
6.5.3. Individuals and their informal carers are provided with advice on how
and where to access evidence-based health information and support.

Education for the interprofessional team
It is essential that the interprofessional team have the skills they need to undertake
evidence based care required to optimise wound healing. Many individuals who
sustain wounds have complex health care issues that influence their ability to heal and
these individuals require health care professionals with advanced skills to intervene
appropriately to optimise healing outcomes.7 It is a professional responsibility to
ensure that one’s clinical skill set is contemporary, evidence based and competent.
Specialised wound practitioners not only perform advanced wound assessment

and management, but also have a significant role in role modelling and providing
education to other members of the interprofessional team.5, 7, 15 International research
demonstrates that facilities that engage a specialist trained tissue viability/wound/
ostomy and continence nurse have lower rates of adverse skin events and improved
healing outcomes for individuals with wounds.15-19
Optimising knowledge for individuals and informal carers
Without knowledge of factors associated with the prevention and development of

a wound and strategies to prevent and manage wounds, the individual is limited in

Standard 6
their ability to actively participate in health planning and delivery. Understanding

the knowledge needs of the individual and their informal carers provides the
interprofessional team with a foundation for planning and delivering education.
Learning needs extend beyond practical wound prevention and management skills
and include knowledge regarding the influence of comorbidities and lifestyle on
wound prevention and healing.
Individuals and their informal carers should have access to contemporary wound
prevention and management knowledge. This may be in the form of one-to-one
education or group education.20-22 Provision of written education material reinforces
verbal education. In developing such resources, consideration should be given
to the language and reading level. Recent studies have shown that less than 1%
of government prepared health education material for patients is targeted at a
reading level below grade 8, which is the Australian average.23
A significant number of individuals access information via the internet; however,

sources are not always complete, accurate, reliable or evidence based. An
important role for health care professionals and health care workers is educating
individuals in appraising the reliability of information sources, identifying sound
educational websites (e.g. government, university or health care organisation sites)
to access, and discussing information that individuals have located to ensure it is
reliable and accurately understood.24
References
1. Seaman S. The role of the nurse specialist in the care of patients with diabetic foot ulcers.
Foot & Ankle International, 2005. 26(1): 19-26.
2. Whiting L, Gleghorn L, Shorney R. Developing a MPM-clinical skill set for tissue viability.
Wounds UK, 2008. 4(1): 41-48.
3. Jones V, Corbett V, Tarran N. Postgraduate diploma/master of science in wound healing

and tissue repair. Int Wound J 2004. 1(1): 38-41.
4. Sibbald RG, Orsted H. The international interdisciplinary wound care course at the
University of Toronto: a 4-year evolution. Int Wound J, 2004. 1(1): 34-7.
5. P. B. The CCARE model of clinical supervision: bridging the theory-practice gap. Nurs Ed
in Pract, 2007. 7: 103-111.
6. Chaboyer W, Gillespie BM. Understanding nurses’ views on a pressure ulcer prevention

care bundle: A first step towards successful implementation. Journal of Clinical Nursing,
2014. 23: 3415-3423.
7. Anderson I. Education saves lives. British Journal of Nursing, 2014. 23(6 Supp): S3-S3.
8. Brunero S, Stein-Parbury J. The effectiveness of clinical supervision in nursing: an evidenced

based literature review. Aust J of Adv Nurs 2008. 25(3): 86-94.
9. Butterworth T, Bell L, Jackson C, M. P. Wicked spell or magic bullet? A review of the clinical
supervision literature 2001-2007. Nurs Ed Today, 2008. 28: 264-272.
10. Brown A, Kendall S, Flanagan M, Cottee M. Encouraging patients to self-care - the

preliminary development and validation of the VeLUSET, a self-efficacy tool for venous leg
ulcer patients, aged 60years and over. International Wound Journal, 2014. 11(3): 326-34.

Standard 6
11. McNichol E. Involving patients with leg ulcers in developing innovations in treatment and
management strategies. British Journal of Community Nursing, 2014: S27-32.
12. Hudgell L, Dalphinis J, Blunt C, Zonouzi M, Procter S. Engaging patients in pressure ulcer
prevention. Nursing Standard, 2015. 29(36): 64-70.
13. Laparra-Hernandez J, Chicote JC, Medina E, Barbera R, Dura-Gil JV, Lozano V, Gil A,
Bermejo I. PUMA project: Active involving of end users to achieve a smart solution to
prevent pressure ulcer. Studies in Health Technology & Informatics, 2015. 217: 901-6.
14. Latimer S, Chaboyer W, Gillespie B. Patient participation in pressure injury prevention:

Giving patient’s a voice. Scandinavian Journal of Caring Sciences, 2014. 28(4): 648-656.
15. Trinkoff AM, Lerner NB, Storr CL, Han K, Johantgen ME, Gartrella K. Leadership education,
certification and resident outcomes in US nursing homes: Cross-sectional secondary data
analysis. International Journal of Nursing Studies, 2015. 52(1): 334-344.
16. Castle NG, Furnier J, Ferguson-Rome JC, Olson D, Johs-Artisensi J. Quality of care and
long-term care administrators education: Does it make a difference? Health Care
Management Review, 2015. 40(1): 35-45.
17. Norris R, Bielby A, Freeman N, Piper B. Applying SSKIN bundle education and dermal pads
in residential homes to improve the quality of care. Journal of Community Nursing, 2015.
29(2): 40-47.
18. Salcido RS. Collaboration for Quality Improvement: Understanding the Process
Improvement Cycle... This month’s continuing education activity on “Improving Processes
to Capture Present on Admissions-Pressure Ulcers” (page 566). Advances in Skin & Wound
Care, 2013. 26(12): 536-536.
19. Bielby A, Norris R, Freeman N, Piper B. Applying SSKIN bundle education and dermal pads
in residential homes to improve the quality of care. Journal of Community Nursing, 2015.
29(2): 40-47 8p.
20. Gonzalez A. Education project to improve venous stasis self-management knowledge.

Journal of Wound, Ostomy, & Continence Nursing, 2014. 41(6): 556-9.
21. Heinen M, Borm G, Van der Vleuten C, Evers A, Oostendorp R, Van Achterberg T. The
Lively Legs self-management programme increased physical activity and reduced
wound days in leg ulcer patients: Results from a randomized controlled trial. International
Journal of Nursing Studies, 2012. 49(2): 151-161.
22. Lindsay E, Tyndale-Biscoe J. Leg Clubs: Helping nurses improve patient outcomes. British
Journal of Community Nursing, 2011. 16(7): 348-349.
23. Cheng C, Dunn M. Health literacy and the Internet: a study on the readability of Australian
online health information. Australian and New Zealand Journal of Public Health, 2015.
39(4): 309-14.
Park, WA.

Standard 7
STANDARD 7
CORPORATE GOVERNANCE
The service provider framework supports evidence based wound
prevention and management.
Rationale
Service providers are accountable to individuals receiving care in the system and
to the interprofessional team and health care workers. Service providers have
a responsibility to ensure continuously improving service quality that promotes
excellent clinical care.
Criteria
The service provider supports wound prevention and management through:
7.1. Evidence based practice is endorsed.1-6
Evidence Criteria
7.1.1. Access to evidence based, documented protocols to guide wound
prevention and management within the organisation is ensured.
7.1.2. Access to evidence based learning for the interprofessional team is

facilitated.
7.1.3. Access to the necessary resources for the implementation of cost

effective, evidence based practice in the prevention and management
of individuals with wounds is provided or facilitated.
7.2. Resources to ensure systematic collection of information are provided.4, 6-16
Evidence Criteria
7.2.1. A systematic process for the collection and security of wound related
health records is in place.
7.2.2. Audits of quality activities for the delivery of best practice in wound
prevention and management are conducted on a regular basis and
the outcomes are actively used to improve care delivery.
7.2.3. Wound surveillance and prevalence surveys are conducted on a regular

basis and the outcomes are actively used to improve care delivery.
7.2.4. Research activities are facilitated and endorsed when appropriate.

Standard 7

Effective clinical governance requires collaboration between services, staff members
and individuals whom the facility serves. Strategies that are shown to successfully
promote strong clinical governance include establishing and maintaining links with
both similar and linked organisations (e.g. ambulatory care services, paramedicine,
pharmacies, general practices, long term care facilities and wound clinics).17, 18
Establishing and nurturing peer networks increases access to resources and
proliferates effective clinical governance strategies at the management level and
evidence based practice at the clinical level. Leveraging external supports (e.g.
state or regional organisations) is also associated with strong clinical governance.17
Promoting excellence in knowledge and practice
Effective continuous quality improvement programs incorporate multiple strategies

to achieve reductions in preventable wounds and promote wound healing.
Engaging the interprofessional team in continuous quality improvement initiatives
is an imperative. Recent literature suggests that skin and wound programs that
incorporate a specialised wound practitioner assigned to deliver wound education,
assist the interprofessional team and health care workers in managing wounds and
take responsibility for wound surveillance/skin assessments is a highly successful
strategy.4, 19 Wound “champions” can play a significant role in teaching, role
modelling and disseminating evidence based practice.4, 19
Consumer participation in health care
Consumer participation in ensuring the service provides high quality care is an effective
component of clinical governance and enshrined in the national standards.6, 20
Partnering with individuals whom the organisation services is demonstrated
through sharing of information; treating individuals with dignity and respect; and
engaging individuals, their informal carers and members of the community in policy
development and safety and quality projects. Promoting rights and responsibilities of
individuals, maintaining transparent communication and responding to the diverse
needs of individuals are important components of ensuring individuals participate
in their own health care and quality improvement within the service.18, 21, 22 This
expectation underpins the Wound Management and Prevention Standard on
Collaborative Practice.
References
3. Kennedy C. The Cochrane Collaboration: informing clinical decision making. Australian

Nursing & Midwifery Journal, 2013. 21(3): 33-33.
Park, WA.

Standard 7
5. Anichini R, Zecchini F, Cerretini I, Meucci G, Fusilli D, Alviggi L, al. e. Improvement of diabetic

foot care after the implementation of the International Consensus on the Diabetic Foot
(ICDF): Results of a 5-year prospective study. Diabetes Research and Clinical Practice
2007. 75: 153-158.
6. Australian Commission on Safety and Quality in Health Care. DRAFT. National Safety and
Quality Health Service Standards. Version 2. 2016: Sydney.
1997: Schedule 1: The Privacy Principles: Principle 4.2: Storage, security and destruction of
personal health information - register of destroyed or transferred records. 1997: Available
at: www.legislation.act.gov.au/a/1997-125/default.asp.
1997 - Schedule 1 The Privacy Principles; Principle 4.1: Storage, security and destruction
of personal health information - safekeeping requirement (3). 1997 Available at:
www.legislation.act.gov.au/a/1997-125/default.asp.
9. Commonwealth Government of Australia. Privacy Act 1988 - Schedule 1, Australian

Privacy Principles. 1988: Available at: http://www.comlaw.gov.au/Series/C2004A03712.
10. Hess CT. Electronic health record wound care checklists. Advances in Skin & Wound Care,
2012. 25(6): 288.
11. Victoria Government. Health Records Act 2001 - Schedule 1, Section 19 The Health Privacy
Principles, Principle 10 - Transfer or closure of the practice of a health service provider.
2001: Available at: www.austlii.edu.au/au/legis/vic/consol_act/hra2001144/sch1.html.
12. Pieper B, National Pressure Ulcer Advisory Panel. eds. Pressure Ulcers: Prevalence,
Incidence, and Implications for the Future. 2012, NPUAP: Washington, DC.
13. Fife C, Walker D, Thomson B. Electronic health records, registries, and quality measures:
What? Why? How? Advances in Wound Care, 2013. 2(10): 598-604.
14. Öien RF, Weller CD. The Swedish national quality Registry of Ulcer Treatment (RUT): How
can ‘RUT’ inform outcome measurement for people diagnosed with venous leg ulcers in
Australia? Wound Practice & Research, 2014. 22(2): 74-77.
15. Weller CD, Evans S. Monitoring patterns and quality of care for people diagnosed with
venous leg ulcers: the argument for a national venous leg ulcer registry. Wound Practice
& Research, 2014. 22(2): 68-73.
16. Hollander J, Singer A, Valentine S, Henry M. Wound registry: development and validation.
Annals of Emergency Medicine, 1995. 25(5): 675-85.
17. Phillip C, Hall S, Pearce C, Travaglia J, de Lusignan S, Love T, Kljakovic M. Improving quality
through clinical governance in primary healthcare. 2010, Australian Primary Healthcare
Research Institute: Canberra.
19. Popovich K, Tohm P, Hurd T. Skin and wound care excellence: Integrating best-practice
evidence. Healthcare Quarterly, 2010. 13: 42-6.
20. Phillips NM, Street M, Haesler E. A systematic review of reliable and valid tools for the
measurement of patient participation in healthcare. BMJ Quality and Safety, 2015.

Standard 7
21. Department of Human Service. Victorian clinical governance policy framework.

Enhancing clinical care. 2008, Vicrotian State Government: Melbourne.
22. Australian Government Department of Health. Charter of Care Recipients’ Rights and
Responsibilities - Home Care, Aged Care Act 1997, Schedule 2 User Rights Principles 2014
2015, DoH: Canberra.

Glossary
GLOSSARY OF TERMS
Adjunctive/adjuvant interventions: Therapies that are used to enhance the healing
effect of standard wound prevention and management interventions. Adjuvant
therapies include biophysical agents (see Biophysical technology), biological agents
(e.g. cytokines, growth factors and collagen), pressure offloading devices, pressure
redistribution support surfaces and dietary supplements (e.g. vitamins and minerals).
Angiography: A medical imaging technique to investigate blockages, narrowing,

inflammation or abnormal widening or bleeding in the blood vessels. Contrast
medium is injected into artery or vein to allow visualisation of blood vessels using
x-ray.
Ankle brachial pressure index (ABPI): A non-invasive vascular test using Doppler
ultrasound that identifies large vessel peripheral arterial disease in the leg. It is used
to determine adequate arterial blood flow in the leg before use of compression
therapy. Systolic blood pressure is measured at the brachial artery and at the ankle
level. The ABPI is calculated as the highest systolic blood pressure from the foot
arteries (either dorsalis pedis or posterior tibial artery) divided by the highest brachial
systolic pressure, which is the best estimate of central systolic blood pressure.1 An
ABPI of 0.8 to 1.1 is usually considered indicative of adequate arterial flow in the
absence of other clinical indicators for arterial disease. An ABPI of less than 0.8 and
a clinical picture of arterial disease should be considered as arterial insufficiency. An
ABPI above 1.2 is suggestive of possible arterial calcification.2
Antibiotic: A natural or synthetic substance administered systemically or topically

that has the capacity to destroy or inhibit bacterial growth.3, 4
Antiseptic: An agent that kills microorganisms.5
Asepsis: “Freedom from infection or infectious (pathogenic) material,”6, p. 81 a

standard of wound management that can practicably be achieved in typical
healthcare settings and the community (as compared to sterile, which can only be
achieved in controlled environments).7
Aseptic technique: A wound management technique that aims to prevent

introduction into the wound of pathogenic microorganisms in quantity sufficient to
cause infection.7
Surgical aseptic technique: required for complex or longer wound dressing
procedures (i.e. longer than 20 minutes) involving larger open wounds, multiple
wounds, or wounds without entirely visible wound beds. Sterile gloves, non-touch
technique and a critical sterile field are used to protect key sites and key parts.7
Standard aseptic technique: used for simple wound dressing procedures that
are shorter in duration (less than 20 minutes) and involve few key sites or key
parts. Non-sterile gloves can be used, and a non-touch technique and general
aseptic field are used to protect key sites and key parts.7
Biofilm: A structured community of genetically diverse microbes that creates
behaviours and defenses that produce unique chronic infections. Essentially microbe
cells stick to both each other, and the surface to which they adhere, producing an
extracellular matrix that contributes to the robust biological structure of a biofilm.
These characteristics significantly increase its tolerance to antibiotics and biocides
and protect it from host immunity.8

Glossary
Biophysical technology: A therapy used to deliver a specific technological treatment

agent/energy to a wound. Biophysical energies are delivered using specially
designed medical devices that require specialized training before use. Biophysical
modalities can be classified in the following categories, although some treatments
deliver more than one energy form.9 Also referred to as adjunctive therapies and
biophysical agents. Categories of biophysical technologies includes:
Electromagnetic spectrum technologies: (e.g. electrical stimulation,
electromagnetic field therapy and phototherapy) Electrical and magnetic
fields are two component properties of electromagnetic radiation. Properties
of these two fields may be altered by the device design so that one or other
is dominant. The therapies use different electromagnetic field frequencies or
wave lengths and create similar physiological responses.9
Acoustic technologies: (e.g. low frequency ultrasound, high frequency
ultrasound) Acoustic technologies deliver sound waves to the tissues to stimulate
healing. Ultrasound devices combine the delivery of sound waves with kinetic
energy from pressure waves causing molecules within tissues to vibrate or
oscillate.9, 10
Mechanical or kinetic technologies: These include therapies that apply
subatmospheric (e.g. negative pressure or suction), kinetic (e.g. pulsatile lavage
or vibration therapy) or atmospheric (e.g. hyperbaric oxygen or topical oxygen)
modalities directly or indirectly to the wound bed with a goal of promoting tissue
healing.9
Biothesiometer: An instrument designed to measure the threshold of vibration an

individual can perceive. The amplitude is gradually lowered until the individual can
no longer discern the vibration.
Body mass index (BMI): An individual’s weight in kilograms divided by the square of
the individual’s height in metres.
Bone scan: A nuclear imaging technique in which a small amount of radioactive

dye is injected into bones to allow assessment of the bone and identification of
bone regions in which metabolism is disrupted.
Callus: Thickening of the stratum corneum (outer layer of skin). Calluses generally
occur as a protective response to friction or pressure, most often forming on hands
or feet, and are painless.11
Chronic wound: A wound that makes slow progression through the healing phases
or displays delayed, interrupted or stalled healing. Inhibited healing may be due
to to intrinsic and extrinsic factors that impact on the person, their wound and their
healing environment.12
Cognition: Mental process of learning, understanding and knowing that is a result

of thought, experience and the senses. It includes knowledge, attention, memory,
judgement, reasoning, decision making, comprehension and language.
Computed tomography (CT scan): A form of x-ray that takes images of the body
from different angles to produce cross sectional images, thereby providing a three-
dimensional impression that is used for diagnostic or therapeutic purposes.
C-reactive protein: A blood test that provides an indirect measure of inflammation

activity in the body.

Glossary
Debridement: The removal of devitalised (non-viable) tissue from or adjacent to a

wound.4 Debridement also removes exudate and bacterial colonies (e.g. biofilm) from
wound bed of and promotes a stimulatory environment. Methods of debridement
include autolytic debridement (promotion of naturally occurring autolysis), biological
debridement (e.g. larval therapy), conservative sharp debridement, enzymatic
debridement, mechanical debridement, low frequency ultrasonic debridement
and surgical sharp debridement.13
Desiccation: The drying of the wound bed and peri-wound.14
Dermatitis/Eczema: A reaction of the skin that often occurs rapidly (acute dermatitis/
eczema), but may be gradual and long standing (chronic dermatitis/eczema). It is
characterised by a red rash, often blistered and swollen, that my be surrounded by
darker, thickened skin (in chronic cases) and is generally dry and itchy. It may be
caused by irritants (e.g. products, chemical or even friction) or allergic response,
and can become infected.15
Devices: Equipment used in the management of wounds that may include (but
are not limited to) ostomy and wound management appliances, negative pressure
wound drainage collection apparatus, tubes, catheters, drains, stents, topical
negative pressure wound systems, pressure garments, orthotics and pressure
redistribution equipment.
Devitalised tissue: Dead tissue presenting as necrotic tissue or slough.16
Duplex ultrasound: A non-invasive ultrasound that evaluates blood flow to detect

adequate flow, clots or venous reflux.
Electrical stimulation: see Biophysical technology.
Electromagnetic field therapy: see Biophysical technology.
Erythrocyte sedimentation rate (ESR): A blood test that provides an indirect measure
of inflammation activity in the body.
Erythema: superficial reddening of the skin.9
Eschar: Black or brown necrotic, devitalised tissue that can be loose or firmly adherent
and hard or soft, and may appear as leathery.3, 13
Exogenous: Originating outside the body.
Extrinsic factors: Originating outside of the body.
Exudate: fluid that is excreted from the wound bed as part of the inflammatory
response and is composed of serum, fibrin and white blood cells. Exudate has a
healing function, for example through providing a barrier to restrict bacteria and
debris entering the wound.17, 18 Exudate types include:
Serous: Thin, watery and clear exudate.17, 18
Haemoserous: Thin, watery and pink exudate.17
Sanguineous: Bloody red drainage, fresh bleeding.17
Seropurulent: Murky, yellow or brown exudate with a thick or creamy consistency.17
Purulent: Thick, opaque pus with an offensive odour.17

Glossary
Fibrin: A protein involved in clotting of blood. When wound bleeding occurs, the
fibrinogen in blood plasma is converted into fibrin by the action of the clotting
enzyme thrombin. Fibrin and thrombin combine with red blood cells and platelets
at the wound site to create a mass that hardens and contracts into a blood clot.19
Fistula: see Sinus tract.
Fistulogram: see Sinogram.
Foreign body: Presence in the wound of non-natural bodies that may be a result
of the wounding process (e.g. gravel, dirt or glass) or arise from wound repair (e.g.
sutures, staples, orthopaedic implants or drains).
Friable: Fragile, easily injured tissue.
Friction (frictional force): The resistance to motion in a parallel direction relative to

the common boundary of two surfaces (e.g. when skin is dragged across a surface,
such as bed linen).9, 20, 21
Gangrene: Gangrene is the death of localised body tissue. It may be wet (occurring
due to necrotising bacterial infections)22 or dry (occurring due to tissue ischaemia
due to a range of causes including peripheral arterial disease, venous insufficiency,
thrombosis, trauma frostbite or embolism).23 Early signs of wet gangrene include
blisters, bruising that precedes skin/tissue necrosis, crepitation and cutaneous
numbness. These symptoms require urgent investigation.22
Granulation tissue: The pink/red, moist, shiny tissue that glistens and is composed of
new blood vessels, connective tissue, fibroblasts, and inflammatory cells that fills an
open wound when it begins to heal. It typically appears deep pink or red with an
irregular, granular surface.3
Glycosylated haemoglobin (HbA1c): A test that indicates an individual’s average

blood glucose level over the preceding 10 to 12 weeks.
Health care worker: In this document, a health care worker is an individual employed
in a role to deliver assistance in managing health but who has not completed a
professional degree or who does not work in a role that is regulated by the Australian
Health Practitioner Regulation Agency.
Health history: Past or concurrent diseases or comorbidities, trauma, surgical

interventions, medication regimens, or other factors of relevance to current health
status and wound prevention and management.
Health literacy: The cognitive and social skills that determine the ability of an individual
to gain access to, understand and use information in ways which promote and
maintain health, including the individual’s motivation to seek out such information.24
Health care professional: An individual who works within a branch of health care
who has completed a professional degree or who works in a role that is regulated
by the Australian Health Practitioner Regulation Agency.
Hyperkeratosis: An increase in dead cells on the surface of the skin (stratum corneum)
that may be referred to as scaling.25

Glossary
Hypergranulation: Also referred to as over granulation. Hypergranualtion is present

when there is excess granulation tissue such that the tissue progresses above the
base layer of the wound bed, presenting as raised, soft, shiny, friable red tissue that
lacks the granule appearance of granulated tissue. Hypegranulation inhibits the
migration of epithelial cells resulting in slowing of the healing process. 26
Induration: Hardening of soft tissues.
Individual: In this document, individual refers to a person with a wound (i.e. a patient,
resident or client).
Infection: when the quantity of microorganisms in a wound become imbalanced

such that the host response is overwhelmed and wound healing becomes impaired.27
Transition from non-infected to infected is a gradual process determined by the
quantity and virulence of microbial burden and the individual’s immune response.12
The transition that can be categorised as:
Contamination: The presence of bacteria within the wound without bacterial
multiplication28 and with no impairment to health or obvious clinical signs of
infection.29 A wound swab and quantitative evaluation is required to detect the
presence of bacteria.
Colonisation: The replication of microorganisms on the surface of the wound
without invasion into wound tissue and without host immune response.30 A
wound swab and quantitative evaluation is required to detect the presence of
bacteria.12
Local infection (covert): (previously known as critical colonisation) early local
infection in which increased microbial burden is characterised by covert signs
and symptoms including static/delay in wound healing, rolled edges, changes
in granulation tissue (e.g. bright friable hypergranulation or pocketing), bridging
of tissues, increased exudate and pain/discomfort.12
Local infection (overt): local infection in which increased microbial burden
is characterised by classic signs and symptoms of infection including pain,
tenderness, warmth/heat, erythema, oedema and purulent exudate.12
Spreading infection (e.g. cellulitis): Bacteria and/or their products have invaded
adjacent or regional tissues causing diffuse, acute inflammation and infection
of skin or subcutaneous tissues.3, 29
Systemic infection (e.g. sepsis, bacteremia): host response to infection includes
systemic signs and symptoms in body systems beyond the skin and surrounding
tissues. Signs and symptoms include loss of appetite, general malaise, pyrexia,
increased white cells and raised C-reactive protein.27
Informal carer: In this document an informal carer refers to a non-employed person

who provides support for an individual with a wound (e.g. a family member).
Interprofessional team: In this document, the interprofessional team is a collaborative

team of health care professionals (e.g. nurses, medical practitioners, surgeons,
physiotherapists, dietitians), who all work together with health care workers, the
individual and informal carers to develop and implement a care plan aimed at
achieving mutually agreed upon the goals of care.31, 32
Intrinsic factors: Originating within the body.

Glossary
Linear healing rate: Linear healing rate describes healing that occurs at a standard
speed (i.e. wound healing progresses by the same amount each day). Although not
all wounds heal in a linear fashion, in general linear healing rate is shown to be a
reliable indicator of healing.33, 34
Maceration: Softening of skin occurring as a result of excessive moisture exposure that

can lead to skin break down, particularly when moisture exposure is accompanied
by friction or shearing force. Macerated skin has a wrinkled, white, soggy and soft
appearance.
Magnetic resonance imaging (MRI): A non-invasive medical imaging technique

that uses magnetic field and radio frequency pulses to create images of the internal
body. In contrast to x-ray, MRI creates more detailed image of organs and soft
tissues, as well as bone and other internal structures.
Monofilament testing: A test that is conducted to detect loss of sensation. Calibrated

nylon threads/monofilaments (sometimes called Semmes-Weinstein mono-filaments)
that are placed on the individual’s skin (usually the foot), with force applied until the
filament buckles. The individual indicates when the buckling sensation cannot be
detected.35
Necrotic tissue/necrosis: Dead (devitalised) tissue that is dark in colour and

comprised of dehydrated, dead tissue cells. Necrotic tissue acts as a barrier to
healing by preventing complete tissue repair and promoting microbial colonisation.
It is usually managed with debridement, but only after a comprehensive assessment
of the individual and their wound.16
Non-concordance: Disagreement between an individual and members of the

collaborative team regarding goals of care of the way in which care will be
undertaken.
Oedema: Oedema is swelling of the tissues causes by accumulation of fluid. Oedema

is classified as pitting or non-pitting. When pitting oedema is pressed with the finger,
an indentation remains after pressure is released. An indentation does not persist
after pressure release if the oedema is non-pitting.
Offload: To remove pressure from any area.9, 21
Osteomyelitis: Infection of the bone that occurs through infection of the bloodstream
(including infection from another point in the body that travels in the bloodstream)
or from a wound or injury that allows bacteria to directly reach bone. Infection is
usually the result of bacteria with gram positive S. aureus accounting for up to 90%
of cases.36
Palliative care: Care focused on holistically supporting the individual for comfort
rather than cure, or healing of the wound, while enhancing the quality of living and
dying.37, 38
Peri-wound: The area immediately adjacent to the wound edge extending out 4cm,
and including any skin under the wound dressing. 39 The peri-wound and surrounding
skin can be affected by moisture (e.g. maceration and excoriation) or may have
dryness, hyperkeratosis, callus or eczema.39 The condition of the peri-wound and
surrounding skin is often a result of management strategies (e.g. contact dermatitis
in response to a wound dressing), but can also be related to the wound type (e.g.
dermatological problems are particularly associated with venous ulcers).39, 40 The

Glossary
peri-wound and surrounding skin can also be indicative of the wound condition
(e.g. erythema, warmth and swelling indicates potential wound infection)39 or of
overall health issues influencing wound healing (e.g. pale or bluish skin can indicate
poor vascular supply).
Peptide nucleic acid fluorescent in situ hybridisation (PNA-FISH): A laboratory-based
method of detecting of bacteria and yeast species directly from positive blood
culture bottles using fluorescent microscopy.41
pH: A measure on a scale from 0 to 14 of acidity or alkalinity, with 7 being neutral,

greater than 7 being more alkaline and less than 7 being more acidic.9
Pharmaceutical: A product or preparation that contains a medicinal drug that is used

either topically or systemically in the management of individuals or their wounds. In
Australia, the Therapeutic Goods Administration is responsible for monitoring and
licensing the sale and use of pharmaceuticals and other therapeutic goods.
Photoplethysmography (PPG): A non invasive test that measures venous refill time
by using a small light probe that is placed on the surface of the skin just above the
ankle. The test requires the patient to perform calf muscle pump exercises for brief
periods followed by rest.42 The PPG probe measures the reduction in skin blood
content following exercise. This determines the efficiency of the musculovenous
pump and the presence of abnormal venous reflux.2
Pigmentation changes: Changes in the colouring of the skin.
Pocketing: This occurs when granulation tissue does not grow in a uniform manner
across the entire wound or when healing does not progress from the bottom up to
the top of the wound. Pockets can harbor bacteria.
Potable water: Water that is fit for consumption by humans and animals.
Pressure injury: A localised injury to the skin and/or underlying tissue, usually over
a bony prominence, as a result of pressure or pressure in combination with shear.
Previously referred to as a pressure ulcer, pressure sore, bedsore and decubitus
ulcer.9, 21
Prevalence: The proportion/percentage of individuals in a defined population who

have a wound at a specified point in time.
Prophylactic dressing: A dressing that is placed onto the skin before any skin
damage is evident with a goal of preventing skin breakdown due to pressure, shear
and alternations in the skin’s microclimate. Features such as an elastic adhesive
type (e.g. silicone), the number of dressing layers and their construction, and the size
of the selected dressing all contribute to its ability to protect the skin.43
Quality of life: An individualised and qualitative measure of the impact of disease

and/or disability and treatment on the individual’s ability to lead a fulfilling life.44
Risk assessment: An assessment that is conducted to determine the presence of

factors known to be associated with a condition (e.g. pressure injuries, incontinence).3
Service provider: Any organisation, institution, facility or company that is responsible

for provision of wound management or related services.

Glossary
Sinus tract: A track or path of tissue destruction, sometimes called a tunnel, occurring
in any direction from the surface or edge of a wound. It results in dead space with a
potential for abscess formation.3, 45
Sinogram: An x-ray procedure in which contrast medium is injected into a sinus tract
in order to create a visual image of the path of tissue destruction. Also referred to as
a fistulogram.
Slough: Soft, generally moist, devitalised (non-viable) tissue. It may be white, yellow,
tan, or green, and it may be loose or firmly adherent.3
Specialised wound practitioner: In this document, a health care professional who has
undertaken a specialist education course in wound prevention and management.
Support surface: A specialised device (e.g. mattress, cushion or overlay) for pressure
redistribution designed for management of tissue loads, microclimate, and/or other
therapeutic functions.9, 21
Toe brachial pressure index (TBPI): A non invasive test that measures arterial
perfusion in the toes and feet. A toe cuff is applied to the hallux (or second toe if
amputated) and the pressure is divided by the highest brachial systolic pressure.
The TBPI is used to measure arterial perfusion in the feet and toes of patients with
incompressible arteries due to calcification as may occur in patients with diabetes
and renal disease.2, 46
Transcutaneous oxygen pressure: The amount of oxygen reaching the skin through
blood circulation. Transcutaneous oxygen pressure is measured via transcutaneous
oximetry, which involves electrodes placed on the skin that create a local hyperaemia
that intensifies blood perfusion and maximises oxygen pressure (mmHg). Usually
measurement is made at more than one site to achieve a good clinical picture.2
Tunneling: See Sinus tract.
Ultrasound (therapeutic): see Biophysical technology.
Undermining: An area of tissue destruction extending under intact skin along the
periphery of a wound. It can be distinguished from a sinus tract in that it involves a
significant portion of wound edge.3, 45
Urticaria: Skin reaction characterised by swelling, hives or welling with hives. Acute
urticaria lasts six weeks or less, while chronic urticarial is longer than six weeks in
duration with daily reaction. Urticaria may occur spontaneously, or in response to
systemic or topical contact with an allergen, infection, vaccination or bee/wasp
stings. It occurs due to release of chemical mediators from tissue mast cells as an
immune response.47
Venous leg ulcer: An ulcer on the lower extremity that is caused by venous disease.
Venous ulceration is a chronic condition that is generally considered to result from
venous occlusion, incompetent calf muscle pump function or venous valvular failure,
giving rise venous hypertension.2
Wellbeing: A dynamic matrix of factors, including physical, social, psychological

and spiritual. Wellbeing is inherently individual, will vary over time, is influenced by
culture and context, and is independent of wound type, duration or care setting.48

Glossary
Wound culture: A sample of tissue or fluid taken from the wound bed and placed in
a sterile container for transportation to the laboratory. In the laboratory the sample
is placed in a substance that promotes growth of organisms and the type and
quantity of organisms that grow is assessed by microscopy. Wound cultures are used
to determine the type and quantity of microorganisms in a wound.49
Wound dressing: A material applied to a wound for a variety of reasons, including

prevention or management of infection; optimisation of moisture balance,
temperature and wound pH; protection; absorption or drainage of exudate; control
of odour or to reduce pain. Wound dressings can be defined as primary (in direct
contact with the wound bed) or secondary (applied over a primary dressing for
added protection or absorption) Wound dressing types are generally defined by
their composition and include (but are not limited to) antimicrobial agents (e.g. silver
or honey impregnated), alginates, collagen matrix, composites, foam, hydrocolloid,
hydrogels, silicone and transparent films.50
Wound edge: The external margin or rim of the wound. The wound edge may be well
defined or have unclear margins, and its condition is an indicator of wound healing
progression. A healthy wound edge is moist, intact and level with the base of the
wound. An unhealthy wound edge may be macerated, dehydrated, undermining
or have rolled edges.39
References
1. Al-Qaisi, M., et al., Ankle Brachial Pressure Index (ABPI): An update for practitioners. 2009.
5: p. 833 - 841.
3. WOCN, Wound Ostomy and Continence Nurses Society. Guideline for the Prevention
and Management of Pressure Ulcers. WOCN Clinical Practice Guideline Series. 2010,
Mount Laurel, NJ: Wound Ostomy and Continence Nurses Society.

Guideline for the Prevention and Management of Pressure Injury. 2012, Osborne Park,
WA: Cambridge Media.
5. Vowden, P., K. Vowden, and K. Carville, Antimicrobials Made Easy. Wounds International,
2011. 2(1).
6. Weller, B., ed. Encyclopedic Dictionary of Nursing and Health Care. 1997, Balliere Tindall:
London.
7. National Health and Medical Research Council, Australian Guidelines for the Prevention
and Control of Infection in Healthcare. 2010, Commonwealth of Australia.
8. International Wound Infection Institute, Wound infection in clinical practice: A 2016

international consensus update. IN PRESS, 2016.
Osborne Park, WA.
10. Korzendorfer, H. and H. Hettrick, Biophysical technologies for management of wound

bioburden. Advances in Wound Care, 2014. 3(12): p. 733-41.

Glossary
11. Oakley, A. Corns and calluses. 2005 DermNet, NZ, http://www.dermnetnz.org/topics/

corns-and-calluses/. [Accessed August 2016].
12. Ayello, E.A., R.G. Sibbald, and S. Baranoski, Wound Debridement, in Wound Care
Essentials: Practice Principles, S. Baranoski and E.A. Ayello, Editors. 2016.
13. White, R., The costs of wound debridement and exudate management. British Journal of
Healthcare Management 2015. 21(4): p. 172-6.
14. Oakley, A. Dermatitis. 1997 DermNet, NZ. http://www.dermnetnz.org/topics/dermatitis/

[Accezsed August 2016].
15. Benbow, M., Wound care: ensuring a holistic and collaborative assessment. British Journal
of Community Nursing, 2011: p. S6-16
16. White, R. and K. Cutting, Modern exudate management: a review of wound treatments.
World Wide Wounds, 2006. http://www.worldwidewounds.com/2006/september/White/
Modern-Exudate-Mgt.html.
17. Cutting, K., Wound exudate: composition and functions. British Journal of Community
Nursing, 2003. 8(9 Suppl): p. A4-9.
18. Editor. Ten Essentials About Fibrin. 2016 [cited August 2016; Available from: Thrombocyte.
com.
19. NPUAP. National Pressure Ulcer Advisory Panel Support Surface Standards Initiative -
Terms and Definitions Related to Support Surfaces. 2007 January 6, 2009]; Available from:
http://www.npuap.org/NPUAP_S3I_TD.pdf.
21. Boyens, H., A. Oakley, and J. Gonez. Wet gangrene. 2016 August 2016].
22. Boyens, H. and A. Oakley. Dry gangrene. 2014 August 2016].
23. Nutbeam, D., Health literacy as a public health goal: a challenge for contemporary
health education and communication strategies in the 21st century. Health Promotion
International, 2000. 15(3): p. 259-267.
24. DermNet New Zealand editors. Hyperkeratosis. http://www.dermnetnz.org/ [Accessed

August 2016].
25. Stephen-Haynes, J. and S. Hampton, Achieving effective outcomes in patients with

overgranulation. Wound Care Alliance UK: http://www.wcauk.org/downloads/booklet_
overgranulation.pdf.
26. Swanson, T., et al., Ten top tips: identification of wound infection in a chronic wound.
Wounds Middle East, 2015. 2(1): p. 20-5.
27. Gardner, S.E. and R.A. Frantz, Wound Bioburden, in Wound Care Essentials: Practice
Principles., S. Baranoski and E. Ayello, Editors. 2008, Lippincott: Philadelphia. p. 111-3.
28. AWMA, Bacterial Impact on Wound Healing: From Contamination to Infection. Position
Paper. 2011, http://www.awma.com.au/publications/publications.php: AWMA.
29. Bowler, P.G., Wound pathophysiology, infection, and therapeutic options. Annals of
Internal Medicine, 2002. 34: p. 419-27.

Glossary
30. Moore, Z., et al., AAWC/AWMA/EWMA Position Paper: Managing wounds as a team.
Journal of Wound Care, 2014. 23(5 Suppl): p. S1-38.
31. Plummer, E.S. and S.G. Albert, Diabetic foot management in the elderly. Clinics in Geriatric
Medicine, 2008. 24: p. 551-67.
32. Edsberg, L.E., J.T. Wyffels, and D.S. Ha., Longitudinal Study of Stage III and Stage IV Pressure
Ulcer Area and Perimeter as Healing Parameters to Predict Wound Closure. Ostomy
Wound Management 2011. 57(10): p. 50-62.
33. Gorin, D.R., et al., The influence of wound geometry on the measurement of wound
healing rates in clinical trials. Journal of Vascular Surgery, 1996. 23: p. 524-8.
34. Dros, J., et al., Accuracy of monofilament testing to diagnose peripheral neuropathy: A
systematic review. Annals of Famiyl medicine, 2009. 7(6): p. 555-8.
35. Bires, A.M., B. Kerr, and L. George, Osteomyelitis: An overview of imaging modalities.
Critical Care Nursing Quarterly, 2015. 38(2): p. 154-164.
36. Langemo, D.K., et al., Evidence-based guidelines for pressure ulcer management at the
end of life. International Journal of Palliative Nursing, 2015. 21(5): p. 225-32.
37. Langemo, D.K., Palliative Wound Care, in Wound Care Essentials: Practice Principles, S.
Baranoski and E. Ayello, Editors. 2016.
38. Dowsett, C., et al., Triangle of wound assessment made easy. Wounds International, 2015:
p. 1-6.
39. Langøen, A. and S. Lawton, Dermatological problems and periwound skin. World
Wide Wounds, 2009: p. http://www.worldwidewounds.com/2009/November/Lawton-
Langoen/vulnerable-skin-3.html.
40. Harris, D.M. and D.J. Hata, Rapid identification of bacteria and Candida using PNA-
FISH From blood and peritoneal fluid cultures. Annals of Clinical Microbiology and
Antimicrobials, 2013. 12(2).
41. Dodds, S. ABC of Vascular Disease: Photoplethysmography (PPG). 2001 [cited 2010
October]; Available from: http://www.simondodds.com/Venous/Investigations/
Photoplethysmography.htm.
42. Call, E., et al., Enhancing pressure ulcer prevention using wound dressings: what are the
modes of action? International Wound Journal, 2013. epub.
43. Pierce, P., Defining and measuring quality of life. Journal of Wound Care, 1996. 5(3): p.
139-40.
44. Baranoski, S., E. Ayello, and D.K. Langemo, Wound Assessment, in Wound Care Essentials:
Practice Principles, S. Baranoski and E. Ayello, Editors. 2016.
45. Wound Ostomy Continence Nurses Society. Toe brachial index: Best practice for
clinicians. 2008 [cited 2010 October]; Available from: www.wocn.org
46. Oakley, A. Urticaria. 2015 http://www.dermnetnz.org/topics/urticaria/ [Accessed August

2016].
47. International consensus, Optimising wellbeing in people living with a wound. An expert
working group review. 2012, Wounds International: London, Available from: http://www.
woundsinternational.com.

Glossary
48. Kallstrom, G., Are quantitative bacterial wound cultures useful? Journal of Clinical
Microbiology, 2014. 52(8): p. 2753-6.
49. Jenkins, M.L. and E. O’Neal, Pressure ulcer prevalence and incidence in acute care.

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STANDARDS

Published by Cambridge Media on behalf of Wounds Australia

Healing Wounds Together

First edition published: 2002

All rights reserved

Wounds Australia is an interdisciplinary professional association for individuals with

Professor Keryln Carville, PhD, STN(Cred), RN, MRCNA, FAWMA

The contributions of Australian individuals, peak bodies and organisations who

Standards for Wound Prevention and Management 1

STANDARD 1: Scope of Practice..................................................................... 4

STANDARD 2: Collaborative Practice............................................................. 8

STANDARD 3: Clinical Decision Making: Assessment................................ 14

STANDARD 4: Clinical Decision Making: Planning and Practice.............. 25

STANDARD 7: Corporate Governance......................................................... 48

2 Standards for Wound Prevention and Management

Standards for Wound Prevention and Management 3

1.1. Performance in accordance with legislation, regulations, scope of practice

1.1.1. Function in accordance with the scope of practice as determined by

1.1.2. Accountability for practice.

1.1.3. Awareness of limitations of scope of practice for regulated and non-

1.1.4. Knowledge of, and compliance with, policies and procedures of

1.2. Implementation of evidence-based wound prevention and management.10-13

1.2.1. Ability to access current evidence from reputable sources to maintain a

1.2.2. Care decisions reflect evidence-based practice.5, 9, 12

4 Standards for Wound Prevention and Management

1.2.3. Safe use of products, pharmaceuticals, therapies and devices in

1.3. Provision of care within an ethical practice framework.2, 3, 5, 7, 15-17

1.3.2. Recognises the rights and responsibilities of the individual, interprofessional

1.3.3. Delivers evidence-based wound prevention and management that is

1.3.4. Addresses moral and ethical dilemmas in delivery of wound prevention

Background and Context

Beyond the minimum education requirements, legal requirements, and competency

• policies and procedures put in place by the service provider.

Standards for Wound Prevention and Management 5

Health care professionals have a responsibility to engage in evidence-based practice

Consideration should be given to meaningful outcomes for specific individuals

Evidence-based practice incorporates the safe and effective delivery of care.9, 12

6 Standards for Wound Prevention and Management

Standards for Wound Prevention and Management 7

2.1. Empowerment of the individual and their informal carers to participate in

• Rights and responsibilities in wound prevention and management.

• The purpose of and options for a comprehensive assessment.

• The outcomes from all assessments, including the ongoing progress of

2.1.3. Opportunities and information exchange that encourage and facilitate

2.1.4. Individuals with non-concordant behaviours receive education, support

8 Standards for Wound Prevention and Management

2.2. Communication that facilitates collaboration and coordination of care.1, 3, 9, 14-18

2.2.1. Communication is undertaken in a manner that is consistent with the

2.3. Recognition of the skills, knowledge, and contributions of the individual,

2.3.1. Awareness of the skills, knowledge and scope of practice of individual

Background and Context

Standards for Wound Prevention and Management 9

Wound management is a multifactorial clinical issue that frequently encompasses

A collaborative approach to wound prevention and management is associated

10 Standards for Wound Prevention and Management

planning and to actively engage in activities that promote prevention or healing of

• assessment of the individual’s ability to engage in care decisions and undertake

• provision of education and support to allow individuals and informal carers to

• recognition of the diverse backgrounds of individuals that require consideration

Such a patient-centred approach is associated with improved preventive care,

Successful collaboration requires individuals to work together as a group within and

Standards for Wound Prevention and Management 11

3. Gottrup F. A specialized wound-healing center concept: importance of a multidisciplinary